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City of Miami Beach Office of the City Clerk
1700 Convention Center Driv~,TM'iarlliE8e~cfh;i4AfBal39
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 Ordinance 2004-3435.
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NAME OF .lOBBYIST: (Last) (Rrst) (M.!)
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SINESS N~ND ADDRESS (Number and Street) catv) (State) (Zip Code)
03 ?--5391 ~~ 5"32.-'130'/ Uft(91We.2 e 'fI//CC.,,')
FAX NU BER: EMAIl:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CU T:
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BUSINESS NAME AND ADDRESS
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~ElEPH NE NUMBER:
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(Number and Street) (City) ,
6-32 -?3t77
FAX NUMBER: (Optional)
Pi-
3 3/2-9
(State) (Zip Code)
J'LI4e/1~ndlR~(?d #/j1fC'C= ~rJ
EMAIl: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTlY OR INDIRECfl Y, A SOfa OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.
SPECIFIC LOBBY ISSUE:
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR OTHER):
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
A) LOBBYIST DISCLOSURE: (Required)
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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":
D Yes ~o: Are YOU lobbying on a Dresent or oending bid for goods. eauiDment or services. or on a
Dresent or oending award for goods. eguioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes !}No: Are you lobbYing on a Dending aoolication for a Deyelooment Aareement with the City or
aDolication for change of zonina maD designation or change to the City's Future Land Use
MaD?
3) Pursuant to Miami Beach City Code 2-484 (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..
lJ Yes 0 No: Are YOU reDresenting a not-for-Drofit corDoration or entity without soecial comoensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. - .) .4-
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I do solemnly swear that all of the foregoing fa are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. ..'
Signature of Lobbyist:
VI. LOBBYIST IDE
ICATION:
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Form of Identification
CATION:
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Form of Identification
o Produced ID
o Produced ID
o Personally known (Lobbyist)
lJ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
,,~~J.~~ Mario J. Medina
S . " ~~~...'~ Commission#DD29198i
tate of Florrda, County of Miami-Dade =*: ";)~= Ex. . F b 17 2008
Sworn and subscribed befgre me ~~;;... :ii'./ plr:~ ~
This ~day of Vv 20t'\ ""~~I~\\ Atlantio Bonding Co., h1c.
State of Florida, County of Miami-Dade
Sworn to and subscribed bef~r7me 0 ~
This l'} day of lflv 20_ -.)
Signature of Publi otary - tate of Florida
Notarization of Lobbyist's signature
FOR CLER
Annual Registration fee: [ ] Yes [ ]No Amoun Paid
Lobbyist Registration Form received and verified b
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05. oc
Date Paid ~
Revised 12/08/04