Francisco J. Ruiz - Lifetime Fitness Vc-^
IV\I A M I BEACH Greg
Office of the City Clerk
1700 Convention Center Drive
Miami Beach, FL 33139
305.673.7411
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
activities. The term "Lobbyists" has specific exclusions. Please refer to City Code Chapter 2, Article VII, Division 3, entitled "Lobbyists,"
for additional information.
Instructions: Please complete all sections of this form and submit the completed form,with the applicable fee,to the Office of the City
Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular
section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City
Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form.
The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs.
Separate registration forms shall be required for each principal represented on each specific issue.
I. LOBBYIST NFORMATION:
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NAME OF LOBBYIST (Last) (First) (Middle Name)
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LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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LOBBYIST BUSINESS TELEPHONE NUMBER CELL R TELEPHONE NUMBER EMAIL ADDRESS C°"••
II. PRINCIPAL FORMATION: ,
NAME OF PRINCIPAL (Last) (First) (Middle Name) 33 I
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PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code
Section 2-482(c):
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: &C....a
• NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
HI. ISSUE TO BE LOBBIED:
Describe with as much detail as is practical, including but not limited to a specific description where applicable of a pending request for
proposal, invitation to bid,or public hearing number.
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VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD.'
I
Signature of Lobbyist: f - .)---7--- Date /O a / to
I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct,
and that I have read or am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: —....„ Date /b c2 /
Signature of Principal: �7�� Date /0 l Ip
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of n on OcA. State of I c,t■A
County of: /AtA•AA( -b,A76____ County of: M tom-,I -VADE
SworR to(or affirmed) and subscribed before me Sworn to (or affirmed)and subscribed before me
this^.45` day of Ook-,4e.r- L 2016, by thisA day of CDC,1-o c � ,2016, by
FP*NCc3co L"v-k-a.. cakAlt..ASC0 6-4"'lZ
NAME OF LOBBYIST NAME OF PRINCIPAL
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FORM OF IDENTIFICATION FORM OF IDENTIFICATION
_Personally Known _Personally Known
Si Lure of Notary Public Sig n re of Notary Public
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Name of Notary, Ty od. °'",tod+ ^r Ctamneri .Name of Notary, Ty.:_ -. . tam.ed
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JASON SALVATORE �:�'•"�'�`t t JASON SALVATORE
S"-:' MY COMMISSION (NOTARY SEAL) , �` ;.] MY COMMISSION#
(NOTARY SEAL) ;. ;.; __... GG030527
∎-ro: EXPIRES:September 14,2020 �E { EXPIRES:September 14,2020
'%°R � Bonded Thru Notary Public Underwriters ____^:•,r tended Thru Notary Public Un ters
10 tit c..VinrL�I LB SY TY CLERK'S STAFF ONLY '.............► _
Annual Registration fee: [IC]Yes[ ]No Amount Paid$ 'So•°O MCR# L1 t 1,e l e x( Date Paid L0-�q-16
Lobbyist Registration For received and verified by: J•s01J SA-4AlrO6,E:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc Revised 08/18/2016
1 The term"lobbyist"specifically excludes the following persons:
Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who
only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether
direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of
not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for
the appearance.
, i
MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.gov
Office of the City Clerk
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1, Fax: 305.673.7254
NAME OF LOBBYIST: /---14K7z_' '(cv). ,T c, /Z
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT
Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or
principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement
(Statement). In addition to any other penalties that may be imposed as provided in
Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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
automatically suspended from lobbying until all fines are paid, unless the fine has been
- appealed to the Miami-Dade County Commission on Ethics and Public Trust.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyist expenditures, as well as compensation .
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I understand annual registration of all lobbyists shall be required for each 12-month period
commencing October 1 of each year, and the fee for such annual registration shall be
$500.00 pursuant to Section 2-482 of the Miami Beach City Code.
Signa . - of Lobbyist Da e
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