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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 2016 JUL -5 i~'.i 1 9° ( 3
LOBBYIST REGISTRATION FORM iC j ;;L_I: ;;: . OFF I C E
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
activities. The term"Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
s.,phone, or e-mail address_
Please notify this office if your information changes: address,
I. LOBBYIST RETAINED BY:
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ME F PRI CI AL/CLIENT:
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BUSINESS NAM AND¢ADDRE (Number and Street) (City) State) (Zip C de) •
`1$b r � d: T'$ s2b- I3 '21, /acLe.,Kdcof�tie1 Vino! ! /• �►41 TELEPHONE N M E FAX NUMBE :(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 BENEFICIARYL
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: 1} 11'.u.SPECIFIC LOBBY-ISSUE:` �"
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Issue to be lobbied(Describe in detail): -------''''-c-.',"- ---7 ---"---
•
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST IS U Re red) %e `000
B) PRINCIPAL'S DIS U (0 O YIST COMPENS T N)�D
(REQUIRED). �1 ---
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 sjicAre you Iobbvinq 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
• Development Issues":
_Yes_ o: Are you lobbying on a pending application for a Development Aqreement 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 •1 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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHAL FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. t
1
Si natur of L byist
I do solemnly swear that .: •. sing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Mi: ''1 ••-- and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: =. -
VI. LOBBYIST IDENTIFICATI• : r =o`_,_ ' '"_ PRIN PAL IDENTIFICATION:
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Produced ID F.. 1 --.9°' ; o, _Produced ID -��=ie �;
Form of Identification K z .j Form of Identification 7,::-...-,0:•0,0;=
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Personally known(Lobbyist) 3. a E _Personally known(Principal) III
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VII. SIGNATURE AND STAMP OF NOTARY:`, _ ? O0 b N. 3 -a n r
sk ,o r;n Y i m = Z
N y C o x F ,
State of Florida, County of Miami-Dade ; co i State of Florida, County of Miami-Dade S v. ' m
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Sworn tot�nd subscribed before me ,T,,'.2, °, Sworn and subscrib-d(before me T . a = 3
This St" day of Jw1 y ,201 CO N o This S day of I 201. y o n lb
`is ature of P ..lic Notary—State of -�'.rida /Signature of Pus`c Notary—State of Flori'"a m d
Notarization of Lobbyist's signature Notarization of Principal's signature — c.
TO BE COMPLETED BY CI CLERK'S STAFF ONLY
Annual Registration fee: [' Yes[ ]No Amount Paid$ SO• CR# 4424/ t`f7�S Date Paid O`'!-•OS-Ib
d
Lobbyist Registration Forrtl received and verified by: _ 0 S4-t,v
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doe Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
MAMIBEACH
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: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: I U 0 ck
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
autom• •_a uspended from lobbying until all fines are paid, unless the fine has been
appe: ed : Miami-Dade County Commission on Ethics and Public Trust.
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Sig 16. ,i Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
Miscellaneous Cash Receipt •
CITY.OF MIAMI BEACH , ,
No.
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X_. 0 Cash 4 Credit Card D Check # $ C �'
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City of Miar�� Wed of I V�7^ ���� �1 �
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000267-0019 Jenel F).. 07/05/2016 09:16AM " •
MCR OPEN
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Payment Amount: 850.00
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. 1c\ (THIS INFORMATION MUST BE COMPLETED) -_ Office of Finance Director
By
Account Number. ( //- O�OJ- 3 e(-/Lft fy -00- 3O 36'.S `�'�' 0 v. u :.-
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