Kent H. Robbins/Miami Beach Citizens Alliance, PAC, Inc.~~ ~~~~~
'"
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 ~
LOBBYIST REGISTRATION FORM ~ ~ ~1
c-s c ~'Z'1
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage,la€feat,~
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommerl-d~tion~ef~the'
City Manager or any city board or committee; or any action, decision or recommendation of any city personnel ding thE'Lime
period of the entire decision-making process on such action, decision or recommendation that foreseeably will be hear~~,,QQr re ed
by the city commission, or a city board or committee. The term specifically includes the principal as well as any empldG~e eyed
in lobbyin/(73~activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. C.,~ ~ "Tl
BUSINESS NAME AND ADDRESS
`~~~~
TELEPHONE NUMBER:
(Number ~ Street)
:.~/ -~ ~
FAX NUMBER:
I. LOBBYIST RETAINED BY:ii
M - ~~„ ~r~ a c..1/~ ~ ~ ~ Z
EMAIL:
~IIaKCe fAC,~nc,
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHI F~F•IC~ PARTNER; R l3B ~EF~,CIAR~ ~ ~ h e ~ ~Gc ~~ r ~G
• IDENTIFY'„T)A`LIL.PERSJOI_NS FIELDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. S/~P,ECIFIC LOBBY ISLSUE: ~4.~ ~Gp~~~ ~ ~ ~ f^ ~~~ ~ ~
cs ~C~ ~ ~ Y C I ~ T S 6 ~ o~r+CGtiJ~ ~ ~s Can d e! c/~ r` lt~ ~S~
Issue to be lobbied (Descr' a in detail): ~,~'~, to ,~ •+!~ nl.Q ~~e~ 5 p (~- Lr 1
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: ~ A-l ~ ~ t ~~aG ~j-.
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
~ G~~ ~~ r~ o ~ ~
.l ", ~ / via- ~ r .~rsona, ~ C~ ~~l'~^e
~Iq~Nj~ ~ ~ o e
'Qn h r- ~~Gr~
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IV. DISCLOSURE OF TERMS AN AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR 077lERf ~} ~
A) LOBBYIST DISCLOSURE: (Required) ~ ~ ~ , _ ~ _
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
The following infonmation must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On 'Procurement Issues":
^ Yes ~IVo• Are you lobbvina on a present or cendina bid for goods, eauiDment or services, or an a
present or cending award for goods, eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes o• Are you lobbvina on a cendina auDlication for a Development Agreement with the City or
auDlication for chance of zoning map designation or chance to the Citv's Future Land Use
Mao?
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 anot-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..
Qr reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDI RES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR TF_ l /REC i~ CALEND R YS~pR./IA STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO (E E D U Oj~d/p PEN h~b~l RING THE
REPORTING PERIOD. J ~ //7~
I do solemnly swear that all of
familiar with the provision t
requirements.
Signature of Lobbyist:
foregoing facts are true and correct and that I have read or am
i in S~io~ 2-482 ~f't~e Miami Beach City Code and all reporting
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
~YPersonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dad
Sworn to d SAVNC
This +~ y,, . node of
~hRINCIPAL IDENTI CATION:
roduced ID f ~ \
Form of Identification
^ Personally known (Princi
.,r
~' ",•,,, i~FiRY HERNANDQ
.-~'~.:~ MY COMMISSION #~ DD 626373
- '~ : EXPIRES: May 3, 2011
State of Florida, County of a~~e eaweaiTxurbtenF'~cunaenvrlmrs
Sworn aricj su~scribed~ bed ~.~ ~~
This da of ~~r 0
- i~-• -- 37M66
Signa re of P pi>I~brlalNolaryAasn. Signature of ublic N - r
Notarization Notarization of Principal's signature
FOR CLERK'S SE~NLY
Annual Registration fee: [ Yes [ ] No Amount P id ~ ~-'MCR # ~' ~~~ Date Paid ~~
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Rev d 12/08/04