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City of Miami Beach Office of the City Clerk '9
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 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
activi erm"Lobb ists" has sp- .ific exclusions. PI s fer to Ordinance 2004-3435
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NA E OF LOBBYIST: -(Last , + /(First) 1 (M.I
• e`�5U <5w a i P.._. 33/3 '
S NEI AM ND ADD S (N ber and Street) (State) (Zip Code) 1
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1-ELEPH9teE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LO=s -T RETAINED BY•
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Ell ' -7M):4--L.
NAM' O .1• CIP•t TENT: / ' / UV° 9IA/t—f ,
Bwro,Nrbte (Number and Street) (City) Q / (S Z � cirri
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TELEPHONE NUMBER: (JJ((�� FAX NUMBER:(Optional) / EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Se • 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: /40A/ iRJ e
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY IN• - •,• 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: C'' A j \,
II.SPECIFIC LOBBY: ISSUE: /
57z fr tern -
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 erson to be lobbied
17
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i i • 04--00,14,1711J2481- Z,cScif4 Ac+/ s41-- L.--------
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 personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)Any inancial,Familial or Professional Relationship
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 0-0
Ak.cov,B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): e, 0
(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 No Are ou lobb in• on a •resent or .endin• bid for .00ds 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
Development Issues":
_Yes o Are ou lobb in• on a sendin. a.•Iication for a Develo.ment A•reement with the Cit or a.•lication 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.
Yz- No: Are ou re•resentin• a not-for-•rofit corporation or entit without special corn sensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY C - - SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS ' •' -. • ON RECEIV'•. IN TH CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SH = = EN IF T- RE HAVE B=EN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. //�
Signature o 11=Ir'ist
I do solemnly swear . all of the ,.r.,going facts . e true a d correct an. at I have read or am familiar with the provisions contained
in Section 2-482 of - iami rity Code . d all reporti g require -nts.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDEN FICATION: PRINCIPAL IDENTIFICATION:
Produced ID �k_l AUfAZ, 1,,; v Produced ID fLOA4 ifI2 fi
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Form of Identification Form of Identification
r
Personally known (Lobbyist) N Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY: a
State of Florida, County of Miami-Dade z a/ State of Florida, County of Miami-Dade
Sworn to aid subscribe• before me LC Sworn --• subscribed before me
.O day of ;•, ,201 a t This day of AI.•e.," , 2015
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Signature of Public Notary—Sta e of Florida ,• *.w;; ,. of Public Notary—State of Florida
Notarization of Lobbyist's signature -_f Notarization of Principal's signature
TO BE COM' E nV( 1,TY LERK'S STAFF N Y � I t/0'
Annual Registration fee: ]Yes[ ]No Amo •t Par�r '`.4,::e . 6.0 •''# Date Paid 1`l
Lobbyist Registration Form received and verified •��` IXE116`'
t':\CLER\$ALL\aFOR 4S\LOBBYIST FORMS\Lobbyist Annu.i Registra!on Form.doc Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
M1AM ! RF4fH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granath:), City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME:
LAP° 17 6-4-12/0/(--
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$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on.Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lo• • t, who fails to file the required Statement by April 30th of each year, shall be
aut• - a vuspended from lobbying until all fines are paid, unless the fine has been
- ed to/3 Miami-Dade Co Commission on Ethics and Public Trust.
Signat Date:
F:\CLERI$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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