Michelle Kohler/Ocean FairwindMIAMIBEACH
City of Miami Beach 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 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,
NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) '
TE"[EPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBY[ST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street)
TELEPHONE NUMBER:
(oty)
(State)
(Tip Code)
FAX NUMBER: (Optional)
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: ~...,/.~ #1~," ~ 1 j~)~,//l~ ~
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: ~ C~J,~ '0 ~ ~ ~'~ o~T~t I~ ~'- t/0O ~J
II, SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail): ~ .~
III. ~ AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
~TV. DZSCLOSURE OF TERMS AND AHOUNTS OF LOBBYZST COHPENSATZON (DISCLOSE WHETHER
~/.4 T RA T~ o~ o ~,~):.
A) LOBBYIST DTSCLOSURE: (Required) ~/~[/~ ~--~9~'~ ~
B) PR[NCIPAL'S DISCLOSURE (OF LOBBYIST 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":
El Yes E~o': Are YOU Iobb¥inq on a present or pendinq bid for qoodst equipment or servicest or on a
present or pendinq award for qoods~ equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes EFt~o: Are you Iobbvinq on a oendinq application for a Development Aqreement with the City 9r
application for chanqe of zonina man desiqnation or chanae to the City's Future Land Use
Map?
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..
Yes [34~o: Are you representina a not-for-profit corporation or entity without special compensation
or reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER Isr OF EACH YEAR, EACH LOBBY[ST SHALL SUBMIT TO THE C!TY CLERK A SZGNED
STATEMENT UNDER OATHt L!S'FZNG LOBBYING EXPENDITURESt AS WELL AS COMPENSAT!ON
RECEZVED~ IN THE CITY OF M!AM! BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN :IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSAT!ON DURZNG THE
REPORT!NG PER!OD. - (~~~.~1~ ~~
Signature of Lobbyist --"'
! do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am
familiar with the provisions contained in Section 2-482 o.f the Miami Beach City Code and all reporting
requirements. C.~._ j j fi_ , ~ /,,i~'~7'
Signature of Lobbyist: // /~/4;~.f_.t..C.4~. /~'t'x ~ .,L .~
Produced ID
Form of Identification
Produced ID
Form of Identification
[~ersonally known (Lobbyist)
V!!. S!GNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This t ~ day of-St~u~l~e-~{, 20nfo
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
//' FOR CLERI~':~ USE~.~NLY ~ ~/C? ~//.,
Annual Registration fee: [ ~]"_Yes.[ ] No Amount Pzai~l~4~,~ / ~S MCR # r~/ 0~-/~7
Lobbyist Registration Form received and verified by: /~/"~ '
F:\CLER\$ALL\MAR[A-H\Lobbyist\LOBBY[ST fORM 05.d~-'~'~
~Personally known (Principal)
Jj~" ],.,~.',~,,. ALFREDo pERBOMO" ,
;.: :,-.. MY COMMISSION # DD 389713
' [ ."-'-= EXPIRES: April 17, 2009
State of Florida, County of Miami-Da ,-- .... ,,~
Sworn and subscribed before me
This ~\ dayof-~l~ldU~i~'~, 200___~'"-'
~ blic~otaL
Signature of Pu ry - State of Florida
Notarization of Principal's signature
Date Paid / /.,~*,/~//'~ J/ / __ Revised 12/08/04