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Freddy H. Pardo - Care Resource NA I AM1 BEACH 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 Cl'iV 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 activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. Fr°1d` NAME OF LOBBYIST: (Last) (F rst) 5ck? ir,A(M.I) Care— Renrc€ 3l ) �isc Itg IP_ r'1iam, . ' S3 I31 BUSINESS NAME AND ADDRESS (Number and Street) City) (State) {Zip Code) SC)- 5 7 ( ■3L ao 1 0 s • 4 rd• •r 01 "sovaw TELEPHONE NUMBER: FAX NUMBER: EMAIL: r3 Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Ccft 'f5ourc NAME O PRINCI'''AL!CLIENT: 3310 L gou(evarcl AM; FL- 2 3131 B INE S N 'D ADDRE S, (Number and Street City (State) (Zip Code) o 3 a3L1 -'d0 3 o.i 7 1 a o� o -{PA (eresvu/re.oi TELEPHONE NUMB R: 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:R(CK SIC ail (SO • PARTNERSHIP OR TRUST:HOLDING,� sse'CTLYfJ��f�_DIR�CT�Y,��o�OR�/10RE�W�N[�Ry�HIP INTEREST IN SUCH CORPORATION, II SPECIFIC;,LOBBY ISSUE: ` Lary Issue to be lo•bied(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 person to be lobbied Aft AO geaCf CoNIrv)O5lar I di 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 Financial,Familial or Professional Relationship F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc I , IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) IV-UV B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). If f J C 1 l°U l t en S A 061 (JVLI1 -Q - t.':' , Gs The following information must be answered: -;r•` 1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": - G- _Yes No: Are ou lobb 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 Development Issues": =,-. _Yes o: Are ou lobb in• on a •endin• 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. 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 CO i i,r-4,SATION RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHA :E Fl ED EVE I —44, HAVE EEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. .l Signatur of obbyist Ir I do solemnly swear that all of th oregoir g facts are true and correct and th t I have read or am familiar with the provisions contained in Section 2-482 of the Miami B ach Cit ode a d all 'IV ing requi -ments. Signature of Lobbyist: 1Aaa" - ,�e,/. _� Signature of Principal/Client: _ , ,t VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID Produced ID— Form of Identification Form of Identification Personally known (Lobbyist) /Personally know • inci�HLEEN S.CHALK • KATHLEEN S.CHALK ; • . ''f NOTARY PUBLIC VII. SIGNATURE AND STAMP OF "''-.T'. NOTARY PUBLIC *02-4-' : STATE OF FLORIDA � : STATE OF FLORIDA �;��:- EE858023 State of Florida,County of Miami-Dade • !;;�+. EE858023 State of Florida, C. . "'': is i�'-'.'12/12/2016 Sworn to pnd subscribed before me �'- ' Expires 12/12/2016 Sworn and subscribe. .- ore - his • da of �r1 I. , 201 — This (0`Wday of 0 fl , 201 J►`at-ig� �i 1,/..j 1 . / /' L�1�� I/i .�.�� ignat'e of'ub is Nom�t�e of Florida S•nature of Public rotary—State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFFF�O Annual Registration fee: [ ]Yes[ ]No Amount Paid MCR# A) Date Paid Lobbyist Registration Form received and verified by: -ltL.Lt,Ca -"`^' F:\CLER\$r:L tafORMS\LOBBYIST FORMS\Lobbyist Annual Registration Forrn.doc • Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc • . . i\AJAMIBEACH , 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: 305.673.7411 , Fax:305.673.7254 LOBBYIST NAME: ED R ,2 p� 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_r.egistered_.to_lobby_on has been .resolved,_or__l_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 autom- sally suspended from lobbying until all fines are paid, unless the fine has been ap• aled o the Miami-Dade County Commission on Ethics and Public Trust. • , 4 y (704 3 S • f re: Date: • i _ ) CD t (.. W �. r� 7 ;e H S® F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc