Gabriel Lopez - Ana Gazarin & Eugenio Torres n
M.IAM[ BEACH
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City of Miami Beach Office of the City Clerk -�
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or
modification of any ordinance, resolution, action or decision of any commissioner-, any action, decision, recommendation of the City
Manager or any city board or committee- or any action, decision or recommendation of any city personnel during the time period of the
entire decision-making process on such action, decision or recommendation that foreseeably will be hear or reviewed by the city
commission, or a city board or committee. The term specifically includes the principal as well as any employee'engaged in lobbying
activities. The term"Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.1)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
Of
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
,Please notify this office if your contact
information changes:address,phone,,or a mail address. . .
I. LOB YIST RETAINED BY:
N (A;4 41N (k
NAME OF PRINCC L/ LI Tky 61= N�
BUSINESS'NAME AND AQQIIESS (Number n Street) r� (City) (State)[ (Zip Code)
1. _
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TELEPHON NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
n.SPECIFIC LOBBY ISSUE:'
Issue to be.lobbied(Describe in detail):
III 'CITY AGENCIES/INDIVIDUALS T, BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date,stating the eneral nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
PC-1VJVA-VJ1V OF 6006 11AQ0KAQt MA9. IALAA�9Z
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,Umilid1:_§r professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or-city ausonnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
e i
Sec 2-482 Any Financial,Familial or Professional Relationshi
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc !'' Ln
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 14 pp /,a dGf/]gN Cr
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 1 aI A IJ J ODI 7 ll r ( /�
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues":
_
Yes o: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or pending
14 award for hoods,equipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes No: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation or change to the City's Future Land Use Map?
3) Pursuant to Miami Beach City Code Section 2-482(h)Any person (except those exempt from the definition of"lobbyist"as set
forth in Section 2-481 above) who.only appears as a representative of a not-for-profit corporation or entity without special
compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
item,shall register with the clerk as•required by this section but, shall not be required to pay any registration fees.
Yes—No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach City-Code and all reporting requirements.
Signature of Lobbyist: �Z� 2
Signature of Principal/Client
VI. LOBBYIST IDENTIFIC ON: PRINCIPAL IDENTIFICATION:
•t
DL Produced ID L 12-0— 2-74 `� 2 l�Cf—(� Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known (Principa!j
VII. SIGNATURE AND STAMP OF NOT .
�io`PRV � 8E8ESTYEN KOVAC$ _
s_ Notary;Pumia`state a lorida, County of Miami-Dade
State of Florida, County of Miami-Dade ' ;s My.Comm..Expires Jan.3g. d subscribed before me
Sworn to and subscribed before me =-. Commission: EE 87 Y P `
This P 201 �'•:';�F«o`;:��
I� d a of t X 01� ,ANA CiAZARIAlV
Bonded,Thfough National Nolary: MY COMMISSION#EE 057901
EXPIRES:January 24,2015
ignat e 9 ub'c No —yState.of Florida Signature of Public Not ry Stagg Q F` a Bonded Thru Budget No"Services
Notarizati of Lobbtr si ature Notarization of Princi s signature
TO BE COMPLET D Y CITY CLERK'S STAFF ON
Annual•Registration feeYes[ ]N o_ Amount,Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by:' 4.
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MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
0
LOBBYIST NAME:
I understand that no later than February 28 of each year, I must file the following form,
pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for
all active lobbying issues.
1) LOBBYIST EXPENDITURE AND COMPENSATION FORM
Failure to file these forms on a timely basis will result in my name being transmitted to
the Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist(or principal) who
fails to timely-file a Statement and in addition to any other penalties which may be
Imposed as provided in Section 2-485.1, a fine of$50.00 a day shall be assessed for all
Statement(s) filed after' the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement orpaythe assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 301 of each year, shall be
automatically suspended-from lobbying until all fines arepaid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
Signature: . Date:
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City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
City Clerk's Office
Tel: 305-673-7411
Fax: 305-673-7254 Office Use Only
ANNUAL LOBBYIST REGISTRATION FORM
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Name: '
Business Name: n O
Address: L J �7 �' o
Office Telephone Number: 74;'
Cellular Telephone Number:
Email Address: (LO q4cJh r d r� l
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If more than one lobbyist, please list: ��. f
1)
2)
3)
4)
5)
6)
7)
Submit this form to the Office of the City Clerk, along with a check for $500 for each
lobbyist. Please make the checks) payable to the City of Miami Beach.
For City Clerk's Office Use Only
MCR#:
Amount paid: Date paid:
Processed by: Date:
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