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1\/\I,t\tV'\I BE1F1 Office of the City Clerk DEC 102020
1700 Convention Center Drive
Miami Beach, FL 33139 CITY OF !-3EACH
305.673.7411 OFFICE 077v f;LER<
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 INFORMAT •N:
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NAME OF LOBBYIST (L st) (First) (Middle Name)
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LOBBYIST BUSIRESS NAME AND ADDRESS ( umber and Street) (City) (State) (Zip Code)
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LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EM ADDRESS
II. PRINCIPAL INFORMATION:
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NAME OF PRINCIPAL (Last) (First) (Middle Name)
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PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip ode)
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PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER gMAIL ADDRESS
%Wain)eV IgiCap @tam 2-482(h)(1)(a,b a principal C./dam corporation, partnership,Cl?CMG?GMea appears m p obbyis CM521b `
DifEadintigl special . �•, �: + t ireimbi.rsementi f(nbt.eN•zx(�}��r(.F ,,Sy�{i � indirect C'contingent,ED M, Cg C2 c;0•asitiont
"pil I Emma� re.uired °/I . . + Irtcl4dell g)CREiJ 2 '9 QB.�f s�f re.istration(b2ta,
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(if none,write N/A):
• NAME OF ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5°/FORE OWNERSHIP INTEREST IN SUCH
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CORPORATION,PARTNERSHIP OR TRUST(if none,write N/A): ( )EE
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III. 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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IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City personnel sought to be
lobbied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with
said City Commissioner or City personnel from 12 months preceding such commencement of service
with the City to the present date, stating the general nature of the subject contractual relationship.
Full Name of Individual and Contractual Relationship (If yes, explain) YES NO
Title of Person to be Lobbied
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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.
List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an
appearance of i propriety(if none,write N/A):
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a
contingency fee is prohibited pursuant to City Code Sec. 2-485.3):
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The following six(6)questions MUST be answered:
1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues":
_Yes 14O:oCAre you lobbying 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 City Code Section 2-490, entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development
Issues":
—Yes c4 o: Are you lobbying 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 City Code Section 2-482(h), any person (except those exempt from the definition of"lobbyist" as set forth in
Section 2-481)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 city clerk as required by this section,but shall not be required to pay any registration fees.
a'-S_No: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement?
4) Pursuant to City Code Section 2-481, 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
reim rsement for the appearance.
es_No: Are you providing only scientific, technical or other specialized information; appearing as a
representative of a neighborhood association without special compensation or reimbursement or
representing a not-for-profit based organization for the purpose of requesting a grant without
special compensation or reimbursement?
5) Pursuant to City Code Section 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months
following thewearing in of any elected official(s)for whom the campaign consultant provided campaign consulting services
within the p t election cycle.See Section 2-491 for more information.
—Yes_ o: Have you provided campaign consulting services to an incumbent member of the City Commission
within the past election cycle?If yes,please list the incumbent member(s)of the City Commission:
_Yes—No: If yes, has it been less than 1r2 months since the elected official s whom ou •rovided cam•ai•n
cons 1Trr�aq s`i~►vices was sworn inR.
6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting
services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section
2-491) shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particular
service before lobbying the City Commission at a public meeting.
—Yes ilc Have you provided campaign consulting services to an incumbent member of the City Commission
within the past election cycle?If yes,please list the incumbent member(s)of the City Commission:
_Yes_No: If yes, were you promised or did you receive economic consideration in e than•e for cam.ai,
consulting se.rwicesr
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: J4Yes[ ]No Amount Paid$ ,es- MCR# 1 -1,/,dc; Date Paid 12/t�,/02.(=>
Lobbyist Registration Form received and verified by: e� (car Jo'-.
F:\CLER\SALL\aFORMS\LOBBYIST FORMS 1Lobbyist Registration Form Revised 09-20.18 REG.doc Revised 09/20/2018
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VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EAC 'EAR EACH LOBBY SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED STATEMENT U!• •ER OATH, LISTING LOBBG EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, FOR THE PR CEDING CALENDAR YEAR WI H REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN EN 0- •GED TO LOBBY. A STAT ENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPEN - ION DURING TH - PORTING PERIOD.'
Signature of Lobbyist: �� _. Date C3 .1
I do solemnly swear • affirm tha . . a.----4"0„.......— Alt
, statements, and disclosures in this form are true and correct,
and that I have read or : ,mi'a , ith the provision tained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code . • . -.orting re.
Signature of Lobbyist: Date i�
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Signature of Principal: J Date IP-
VII. NOTARY SIGNAT - .! ' .
LOBBYIST: �,��y PRINCIPAL I^ 74-
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State of 0,)/'0 % State of /U��� "o
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County of: _ ' ' r i : County of: 1 k " 1 --—/X 6
Sworn to(or affi ed)and subscribed before me, Sworn to(or affi ed)and subscribed before me,
by means of physical presence by means ofphysical presence
or 0 onli - notarizati• or 0}online notari tion,
this • d day of ere. / n" , 20244 this 9" day of , -� , ,209y
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NAME OF LOBBYISTNAME OF PRINCIPAL
Produced ID 06r�/2 L1 7 SC_ ?(Produced ID Of ,
I Vele ,L, c� Se
FORM OF IDENTIFICATION FOF IDENTIFICATION
_Pers• ally Known _Pers' ally Known
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Sign. i re of ► > ary Public Signa ure ofary Public
Name of Notary,Type ed@arthostin Name of Notary, Typed, Printed or Stamped
,r+.;:..;' •�, NOTARY PUBLIC
o: �' SSTATE OF FLORIDA pg Charles J.DA ostin
(NOTARY SEAL) o Y''_ _ (NOTARY SEAL) ao „ c 9
Comm#GG168171 a NOTARY PUBLIC
�, INCE 14'► Expires 12/14/2021 ;i+ STATE OF FLORIDA
Comm*GG168171
1 The term"lobbyist"specifically excludes the following persons: s'C. 141 Expires 12/14/2021
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.
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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
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NAME OF LOBBYIST: / 6r)E77
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 $50.00 a day shall be assessed for Statements filed after the
due date. The City. Clerk shall notify the Miami-Dade County Commission on Ethics and
Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyist expenditures, as well as compensation
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I un• .n• annual regi 'on of all lobbyists shall be required for each 12-month period
•mmencing October 1 of eac year, and the fee for such annual registration shall be
500.00 pursuant to Sectio -482 of the Miami Beach City Code.
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Sign..•a of Lobby Date
F:ICLERI$ALL1aFORMSILOBBYIST FORMS1Lobbyist Registration Form Revised 03-11-20 REG.doc
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