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Rene D Gueits - Salsa Dance International . 4, ie fAiatop‘ in MAMBEACH 1 :50)AL, 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 actin , decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. T e term specifically includes the principal as well as any employee engaged in lobbying activities. The term"Lobbyists" s specif exclusions. PI efer to Ordinance 20 35. NAME O LOBBYIST: (Last) First) ( .l) A ifyie DTh-ii 4/ :;-4/3 e, -.5,) 9037" /601 ; 33/6LS BUSINESS NAME AND ADDRESS' (Number nd Street (City) (State) (Zip Code) 305 cilaD7Itc 3aS 92o ( 23T7 12sAls41.zveye..sv/Ahoo TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information chang address,phone, or e-mail address. I. LOBBYIST RETAINED BY: 7.... ...._ 4. NAME 0 '�I S:AVC ly iI I. ' /iA &KEW 'Y')__Cr- � 6,-5' BUSII irE :57/ 5 (Numb� gi f ity)61 (State) (Zip Code) TELEPHONE NUMBER: /J / FAX NUMBER:(Optional) l EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)1 • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: G616i) • IDENTIFY ALL PERSONS HOLDTI 1�G�b �LY DIRE LY,A 5% 4'l OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: f� 1(A) `() ILSPECIFIC LOBBY ISSUE: "An' bavA Pc/1413h ppihpiepickeyys Issue to be lobbied(Describe in detail): Ill.CITY AGENCIES/INDIVIDUALS TO 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 general nature of the subject contractual relationship. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of per on to Z lobbied VCI na• cal Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city•persoriffel who is sought to be lobbied as identified on the lobbyist registration form filed. _ - 1 N - Sec 2-482(g)Any Financial,Familial or Professional Relationship •• ant /Vo T- Fv,z -ez-)ti F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc per/ 0 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) v B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): D (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_i4 o: Are ou Iobb in• on a •resent or •endin• bid for •oods e•ui•ment or services or on a •resent or •endin• 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 Dev opment Issues": _Yes_ o: 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. es No: Are you representing a not-for-profit cor cation or entity without spe ompensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBY ALL SUBMIT TO THE CITY CLERK SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS—CMMQPENSATION - -EIVED, I HE CITY OF MIAMI BEACH FOR THE PRECEDING CALEND• :_. NT SHALL BE -' , N IF TH '- HAVE BEEN NO EXPENDITURES OR COMPENSATION DU- • THE REPORTING PERIOD. 414 —''11111 isy-,� :i••byist I do solemnly swear that all o foregoing facts are tru- - • • - •nd •- .ve read or am familiar with the provisions contained in Section 2-482 of the Miami Be- - sty Code and . sorting require -nts. Signature of Lobbyist: Signature of Princip. 'ent: VI. LOBBYIST IDENTIFIC' PRINCIPAL IDENTIFICATION: • Produced ID 'IZ�b! •. , (zo •�, a yam• roduced ID r ��J��S.. Form of Identification z``' o .•,'4) ' Form of Identification ,, k- , •y ° ``• �° Personally known(Principal) /I�w `� Personally known(Lobbyist) •r <c, .° Y ( P ) e ° r AT VII. SIGNATURE AND STAMP OF NOTARY: / " � F.�yy` c,Ci 4 W c o V F� u State of Florida, County of Miami-Dade ,s`... $ c,°�D State of Florida,County of Miami-Dade 4 I ZS. 147. Sworn to and sus:. ibed Before me """'��`s ca .orn argsubscribed before me =' a E a AffirWA / N O , , 2O15 _ O g�. This �S •= • :� 201 �a` •••� "Q= his��5 day• , a. -► •. O. / ,.0_11.1, O Signature o ui lic Notary— ' ate of Florida ]t�� Signature of Public Not.- - ate of Florida •;o`-„ '�io-, Notarization of obb ist's signature Notarizati.n of Principal's signature = r,`_Xs St. - hc •TO BE COMPLETED BY CITY CLERK'S AF O LY •.•4,�• •�'A•; Annual Registration fee: [,/ Yes[ ]No Amount Paid$ A/IF/P MCR# Date Paid ea._._ Lobbyist Registration Form received and verified by: e Rog.- to--h 0 t A-- F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc NV AM B F AC H City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 ,Fax:305.673.7254 LOBBYIST NAME: aJE 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 theent or pay the assessed fines after notification. A y lobbyist, who fails to file +•e required Statement by April 30th of each year, shall be a •matically suspended from I•bbying until all fines are paid, unless the fine has been appe ,d to the Miami-Dade •unty Commission on Ethics and Public Trust. �� j rs Si• _rr/� ate: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc