Alan Lopez-Blazquez - Baptist Health South Florida, Inc. MIAMI
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
w {_.miarnibeachfl_gov
City Clerk's Office
Tel: 305-673-7411
Fax: 305-673-7254 Office Use Only
ANNUAL LOBBYIST REGISTRATION FORM
Name: ANA LOPEZ-BLAZQU EZ
Business Name: BAPTIST HEALTH ENTERPRISES
Address: 9350 SW 72ND STREET, SUITE 118, MIAMI, FLORIDA, 33173
Office Telephone Number: (786) 596-2636
Cellular Telephone Number:
Email Address: AnaLB @baptisthealth.net
If more than one lobbyist,please list:
1)
2)
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3) _- a r
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7)
Submit this form to the Office of the City Clerk, along with a check for $500 for each •
lobbyist. Please make the check(s) payable to the City of Miami Beach.
For City Clerk's Office Use Only
MCR•#: 1/0 q
Amount paid: Date paid: //-27/6—
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Processed by Gt✓l a-iL. Date: //2 7 /c
F XALIE$ALL'aFORMS-0BEVIST FORMEAANNI1AL LOBBYIST REGISTRATION PORN ueg.dxx
I AM I fMAMI1EACH
City of Miami Beath 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 foreseea.bly will be heard 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 20044435.
Lopez-Blazquez Ana
NAME OF LOBBYIST: (Last) (First) (M.I)
Baptist Health Enterprises 9350 SW 72ND ST Miami Florida 33173
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(786) 596-2636 AnaLB @baptisthealth.net
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
I_ LOBBYIST RETAINED BY:
Baptist Health South Florida, Inc
NAME OF PRINCIPAL/CLIENT: Ka
Baptist Health South Florida,Inc 6855 Real Road,Suite 500 Coral Gables FL 33143
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) gip Code)
(786)662-7272 AnaLB @baptisthealth.net
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: �i
• IDENTIFY ALL PERSONS HOLDING.DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: ''• _ �i
ILSPECIFIC LOBBY ISSUE:
Planning Board consideration of conditional use at 709 Alton Road, Miami Beach FL °'
Issue to be lobbied(Desorbe in detai): Y c^3
W.CITY AOENCIESIINOIVICUALS TO BE LOBBIED: n,
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 person to be lobbied
Planning Board X
Planning Department Staff X
Pursuant to City Code Section 2-422(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 personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial,Familial or Professional Relationship
NONE
IV_ DISCLOSURE OF TER7,S AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY.FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required) $°
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $0
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Seen 2-488 Entitled Prohibited Campaign Contributions By Lobbyists On Procurement
issues':
® Yes NI No: Are you Iobbvinst on a present or pending bid for goods,equipment or services.or on a present or pending
award for goods,ecfuipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled Prohibited Campaign Contributions By Lobbyists On Real Estate
Development issues": '
0 Yes IR No: Are you Iobbvin€r 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 2-484(h)Any person(except those exempt from the definition of°lobbyi.st"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.
0 Yes N o: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement _ ,
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th 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 S E 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 Mia • h City C•de and all -porting requi -.-- .-.
Signature of Lobbyist -1A■ —i
Signature of PrincipalfClient: �u � _
Vi LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ji
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I O � l _pomp WS® Produced ID o N N ® Produced ID ac ,ri p �'
Form of Identification ' 4 — e tV 13 Form of Identification o , 2V . I
fS �° 6a. /" N d $ •
Personally known(Lobbyist) 1 v=i H Personally known(Principal) < o .� x o
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VIL SIGNATURE AND STAMP OF NOTARY', c d €' E 4 , ° . E E
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State of Florida,County of Miami-Dade 4- o " State of Florida,County of Miami-Dade z 2
Sworn to d subscribed before me ( z Sworn and subs before me
eeeoo,,,, V:-, • �0��•i
This d day of t• .'2B�H-�o15' �,�,A�c • roz,,' Thi ,, y of chin , : , • �e�::
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tip, • ._. ►_� owl� . _..r` _, I ri ' 7 , 4. \. IP 01 I ,--G••• ,:,Si •:`i � ''•'o •`�= Si natu to of Public Notary ii State of Florida ,,'� �'.
�agnatu - of Public Notary—S -to of Florida •,,� . g.�,. g �
Notarization of Lobbyist's signature ""'"�� Notarization of Principal's signature
TO BE COMPLETED BY girt CLERKS STAFF ONLY
Annual Registration fee: If 1 Yes 1 1 No Amount Paid$ q .) thcit# y0/y 21 Date Paid l 2 Z /6--
Lobbyist Registration Form received and verified G.:®--4`�F:tiLEM,$ rhaFoR ILoB�s6 FOR b ybt Annual fbegist.r dgnn.d c
Revised 1/1112011
• MIAMBEACH
City
a Miami Beach 1700 Convention Centel Drive,Miami Beach,Florida 33139,www.miamdmachil.gov
CITY ARK Oboe CQtyClerk @miamibeach.ftgov
Te4_305.673_7411 ,Fax:305.673.7254
LOBBYIST NAME:
Ana Lopez-Blazquez
I understand that no later than February 28th 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, I am required to
immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
a t� 1s
Signature: Date:
LaRosa, Clara
From: Alan.Krischer@hklaw.com
Sent: Tuesday,January 27, 2015 2:45 PM
To: LaRosa, Clara
Subject: Baptist lobbyist registration
Importance: Low
Clara,
Per our discussions,the CEO of Baptist is Brian Keeley—and all of the entities are not-for-profit corporations except for
BHE, which is 100%owned by Baptist Health South Florida (which is a not-for-profit).
Alan
Alan Krischer I Holland&Knight
Partner
701 Brickell Avenue,Suite 3300 I Miami FL 33131
Phone 305.789.7758 I Fax 305.789.7799
alan.krischer@hklaw.com I www.hklaw.com
lcld to■c.dress slok Ji tvLrofessiona'-�o raNf y
NOTE: This e-mail is from a law firm, Holland &Knight LLP("H&K"), and is intended solely for the use of the individual(s) to whom it is
addressed. If you believe you received this e-mail in error, please notify the sender immediately, delete the e-mail from your computer and
do not copy or disclose it to anyone else. If you are not an existing client of H&K,do not construe anything in this e-mail to make you a client
unless it contains a specific statement to that effect and do not disclose anything to H&K in reply that you expect it to hold in confidence. If
you properly received this e-mail as a client, co-counsel or retained expert of H&K, you should maintain its contents in confidence in order to
preserve the attorney-client or work product privilege that may be available to protect confidentiality.
1
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City of Miami Beach-Florida
Finance Department
1 City Hall
1502713-1 01/27/2015 BR1 T121
Tue Ja 27,2015 03;15PM 1rar:s#80-80
80 $850.00 MCRCLERK - MCR-City Clerk
* MCR#: 401429
1 ITEM ..850.00
Check (305345) RAID $850.00
Have a nice day!
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