Eriberto Jimenez - Miami Hispanic Ballet Corp. c GRIT-
RECEIVED
t\/\I,At"AI Office of the City Clerk 2022Y —3 PM 2' 07
1700 Convention Center Drive
Miami305.673�FL 4113139 OF ICE OF THL Cill�f CL CLERK
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 "Lobbyist" 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 INFORMATION:
Jimenez Eriberto
NAME OF LOBBYIST (Last) (First) (Middle Name)
Miami Hispanic Ballet Corp. 111 SW 5 Ave. Miami Fl. 33130
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) , (City) (State) (Zip Code)
786-747-1877 786-278-0474 contact@miamihispanicballet.org
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
Same as Above
NAME OF PRINCIPAL (Last) (First) (Middle Name)
PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
REEIMill m EV(§):1221 Section 2-482(h)(1 ;Q principal COW corporation,ITT"nership Ct7 eCfa C a 9 ' o)appears a3 a lobbyis cm bgtfl7c2915
S IJ compensation CB or alg a (o , Cp co ti gent„lt]C •g CQCE a.position tto
=n I em shall register with the clerk as required by this subsection but shall not be requited to pay any r-gistration fees,
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): Eriberto Jimenez
• NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION,PARTNERSHIP OR TRUST(if none,write N/A): N/A
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i
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.
Miami Beach Cultural Affairs Council Grant Application
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
Miami Beach Cultural Affairs Council Grants X
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 impropriety(if none,write N/A):
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):
N/A
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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 )4No: Are 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 XNo: Are you lobbvinq 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.
.XYes_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
reimbursement for the appearance.
_Yes XNo: 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 the swearing in of any elected official(s)for whom the campaign consultant provided campaign consulting services
within the past election cycle.See Section 2-491 for more information.
_Yes XNo: 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. 12 months since a the elected official(s) whom you provided campaign
consulting se..ices was sworn ins.
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 )4,lo: 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 exchange for campaiq
consulting ser ricesr:
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ [Yes( ]No Amount Paid$ MCR# r ` Date Paid
Lobbyist Registration Form received and verified by: J�
F:\GLER\$AL"L,\aFORMS\L08S,YYST'FORMS\Lopbyist Registration rorm,Revised 03=F1-20 REG.doc Revised 03/11/2020
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VI. SIGNATURES UNDER OATH:
ON
SIGNED ST STATEMENT UNDER OATH,ACH LISTINGBLOBYIST BYING EXPENDITURES, AS'SHALL SUBMIT TO THE L /A5 VO ENSATION
RECEIVED, FOR THE PRECEDING CA NDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGE TO BBY.A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSAT N ING THE REPORTING PERIOD.1
Signature of Lobbyist: Date April 28/2022
I do solemnly swear or affirm that II of the foregoing facts,statements,and disclosures in this form are true and correct,
and that I have read or am famiii with a provisions contained in Chapter 2,Art.VII, Division 3,entitled"Lobbyists"of
the Miami Beach CI Code and re o 'rements.
Signature of Lobbyist: Date 4/213/10 ZZ
Signature of Principal: Date y it2 8 (..149 o.2
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of f Lo R 1 b n State of c L o R t- A
County of: PmPr MI-) E County of: IM I A MI— 1,AV C
Sworn to(or affirmed)and subscribed before me, Sworn to(or affirmed)and subscribed before me,
by means of titi physical presence by means of kl physical presence
or 0 online notarization, ,- Q or❑o line notari tion,
this a g� �dayy of *OW .20 by this day o ,20..22,by
Flu hd/rX o i rV �u p,,,94) GO laid-� -.NY1 PRIM
NAME OF LOBBYIST "" NAME OF PRINCIPAL
_Produced ID _Produced ID
FORM OF IDENTIFICATION FORM OF IDENTIFICATION
Personally Known jPersonaliy Known t.._
Si ature of ota P lic Si nature of Notary Public
ry
AOA .440tA- SIA.S0 12TD p'NA pi A A mst>'Rp
Name-of Notary,Typed,Printed or Stamped Name of Notary,Typed,Printed of Stamped i',. .
ANA h1ARIA BASURTO NOTARY SEAL ,eY^++a, .,;;ANA h1ARIABASl1EtTO":(NOTAIbYI_);,' ( )
,* ** Commisslon#GG 215608 * ..7 y Comm... .i GG`�15608, r
TA ,f Expires August 27,2022 .P.,k-Vk'3oT' ^;Expires;,August•27;2022^
' }0F �� a,ux� nn,64;0potar smices g persons: 94•OF E�.°P 'ea,aa!nw&ad9etRZIalSet9 c;
The term"lobb is�"specificallyexcludes the following
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 Eriberto Jimenez/ Miami Hispanic Bagegbfribeachfl.gov
Tel:305.673.7411,Fax:305.673.7254
NAME OF LOBBYIST: Eriberto Jimenez/Miami Hispanic Ballet Corp.
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 unders nd annual registration of all lobbyists shall be required for each 12-month period
comme cing 0 tober 1 of each year, and the fee for such annual registration shall be
$500.0 pursu t to Section 2-482 of the Miami Beach City Code.
April 28/2022
Signature f Lo ist Date
April 28/2022
FACLEm5ALMFORMSLLOBBYIST FORMSLLobbytst Regtt2aOon Fan Revised 03-11-20 REG.doe
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