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City of Miami Beach {]ffioa of the City Clerk
1700 Convention Center Drive, Miami BeoCh, FL 33138
LOBBYIST REGISTRATION ronM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the paaaago, defeat or
modification of any ordinance, ,euo|udnn, action or decision of any commissioner; any actinn, deuiuion, recommendation of the City
Manager or any city board or committed, or any action, decision or recommendation of any city personnel during the time period of the
entire decision-making pmoaaa on auc� acdnn, decision or recommendation that fonaoeeab|y will be heard or reviewed by the city
commisamn, or a city board or committee. The u*nn anao|fioaxy mo|uuea the principal as well as any employee engaged in lobbying
activities. The term ^Lnuuyiots" has specific exclusions. Please refer to Ordinance zUn4'n43e.
Code)aaeh-� t L//I-T-0 9 1 V 2,A F1 Af24
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip ��' ���� � 14 �
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notity1his mffine/f your omntoot/nfornnetion oNangeaa�eddneaa,phone, or e-mail address.
/. LOBBYIST RETAINED BY:
NAME OF P"'=C',AU^LIF- V �
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE 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 HOL&Q�DIRECTLY,OR INDI LY,A 5%OR OWNERSHIP INTEIREP�=�i.&4_4RPORATION,
PARTNERSHIP OR TRUST:
x.SPEClF|C LOBBY ISSUE; x� �A ����^
` �� ��� � �� �~*�»�� | . ' ^~Cf4
Issue to be lobbied(Describe in detail):
III.CITY AGENCIES/ NDIVDUA �13F LOBBIED:
Pursuant to City Code Section 2-482(a)(4)include the mmi personnel sought to be muumm 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
) ��a,u shall uo imumuo��moox�,um any uuomonw.nnon�m.�mixo|o,nmmooiono|
Pursuant -'- ,nauvn^mp<ivinmnnemoanunnwomnoemanimpmnwmmwuhunvcunoruouvcommiominno,o,cuvpo,ounno|wxv/o or other
sought uo6v lobbied oo identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial, Familial or Professional Relationship
VIr
1
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED).
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-Who: Are you lobbyinq on a present or pending bid for goods,equipment or services,or on a present or pending
award for goods,equipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
/No:Deve Issues":
Yes 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:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
' Produced ID �L- �1 b33 63 0y-v ✓ Produced ID raL# &;I-
Form of Identification Form of Identificatio
Personally known(Lobbyist) Personally known(Princ' :,y •
VII. SIGNATURE AND STAMP F� LILLIAN BEAUCHAMP �'•` ••
y •,I�o',,
� Notar Public•State of Florida
State of Florida,Count of Miami-Da "• • tate of Florida,County of Miami-Da o- y ��
Y .s My Comm.Expires May 5.2018
Sworn to an subscrib be re me '-;f„ ,?;:••' Commission ar FF 119190 worn and subscri d efore me
This day of ,2 1 his y of ,201j
44igature of Public Notary-State of Florida V Qnature of Pubic Notary-State of Flori
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# �/�— Date Paid
Lobbyist Registration Form received and verified by: '
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc o Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
• ;i" } HI
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: �` u ?
1 eo 0T-D ,
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 or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Mia ade County Commission on Ethics and Public Trust.
04
Signature: Date:
FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 5-22-14.doc