Jose Suarez/The Related Group City of IVliami 8each 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 prindpai who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or dedsion of any commissioner; any action, derision, recommendation of the
City Manager or any dty board or committee; or any action, dedston or recommendation of any city personnel during the time
period of the entire decision-making process on such action, decision or recommendaUon that foreseeably will be heard or reviewed
by the city commission, or a dry board or committee. The term specifically indudes the pdndpal as well as any employee
/n lobbying activities. The term ~Lobbyists' has spedflc exdusions, Please refer to Ordinance 2004-3435.
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EmiL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/O. IENT:
I~S[NES$ NAME AND A~REs5 (Nu~ and s~) (O~) -
P. OA.4 '
(state)' ' J(Tip Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICJARY:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA'I'[ON, PARTNERSHIP OR TRUST:
A) Full Name of Individual/TiUe
,'rI
d/,"I
lB) Any Financial, Familial or Profemdonal Relationship
2) {WJrmum~ 10 M{sng BEach City c"JYb 2-4g0 ~ "PTohibil~d Clrnl~{gn ~ ~P Labby{~ Off Real
V. SIENATU~ UNNIt OAlPlI:
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DTSCLOSURE OF TERMS AND AHOUNTS OF LOBBYIST COMPENSA'r~ON (DZSCLOSE WHETHER HOUR£ F/
F~4 T RA TE OR 077fER):.
A) LOBBYIST DTLSCLOSURE: (R~quire~)
B) PRINCIPAL'S DTSCLOSURE (OF LOBBY[ST COMPENSATION): (Required:).
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 t~o: Are you Ioblwina on a present or Dendina bid for aoods, eouioment or services, or on a
" present or ~endin~ award for ¢mods. ecluiDment or service?
r2) Pursuant to Miami Beach CKy Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estat~ Development Issues":
[~Yes ~io: Are you Iobbvina on a Dendina aD~icaUon for a Development Aareement with the City or
aoolicaUon for chanae of zonina mad desianaUon or chanae to Ute City's Future Land Use
MaD?
3) Pursuant to Miami Beach City Code 2-4~ (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representalJve 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
pion but, shall not be required to pay any registration fees..
Yes ~ No:. Are you reoresentJno a not-for-profit con~oration or entity without sDecial compensation
or reimlmrsemnl~ .
V. S~GNATURE UNDER OATH:
ON OCTOBER 1sr OF EACH YEAR, EACH LOBBY[ST SHALL SUBMTT TO THE CZTY CLERK A SIGNED
STATEMENT UNDER OATH, LZSTZNG LOBBYZNG EXPENDI"TURES, AS WELL AS COHPENSATZON
RECEDED, IN THE CZTY OF HZAIq! BEACH FOR THE PRECEDING CALEND/)R~YEAR. A STATEMENT
SHALL BE FILED EVEN ,F THERE HAVE BEEN NO EXPENDTrlJRES OR ~SATION DURZNG THE
I do solemnly swmr that all of the foregoing facts are tru~and correct and that I have read or am
familiar with the pro~$ions contained in Section :>-482 of ~e Miami Beach O~ Code and all reporting
requirements. ~_
Signature of Princlpal/Qient:
VZ. LOBBYZST IDENTIFZCATZON:
PRZNCZPAL ZDENTZi~CATZON:
!'i;~ Produced ID ~:, Produced ID
Form of Identification Form of Identification
.:~Personally (Lobbyist) .~p ,q.~.,~6.,. Personally known (Principal)
known
VZZ. SZGNATURE AND STAHP OF NOTARY, O"~' ,.~:~"~'~'''~--
State of Flonda, County of M~mFDade .~cp~. ~q..~F' .a~' State of Rorida, County of Miam,-Dade
Sworn to,alnd subscdb~L~f?re me _.~.w~u~', ~,+~- Sworn and subscribed before me
Signature of Public Notary - State of Rorida Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ ] Yes [ ] No Amount Paid MCR #
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MAFEA-M\Lobbyist\LOBBY[ST fORM 05.doc
Date Paid
Revised 12/08/04