Roberto J. Gambach/Eduardo Bottem MIAMIBEACH
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 derision of any commissioner; any action, deasion, recommendation of the
City Manager or any dry 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 spedfic exdusions. Please refer to Ordinance 2004-3435.
G,a m P1~ e r3 lQo /3 ~-z.-~-o
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) - (State) (Zip Code)
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LOBBYIST RETAINED BY:
EMAIL:
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NAME
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BUSINESS NAME AND DDRE (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) /LQ~~
out this section if principal is a Corporation, Partnership or
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE: ~'y ~~ //o . 3 / / ~
ExT~~JS~a/ O~ T!/yI ~ To d~',9/~/ ~dtLD/n~Gs ~~rPr~oJT 1'002 S 1 Z7 C,2~LS~i
Issue to be lobbied (Describe in detail): ~L y,,~
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
~JoA~~ oG A a ~v5r~ ~ N-f
B) Any Finandal, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OJHERx ,
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). o`~ f 7
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 C;f"No: Are you lobbvina on a present or pending bid for goods, equipment or services, or on a
nrpeent or oendina award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled ~~Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes P1 No: Are you lobbvina on a oendina auulication for a Development Agreement with the City or
application for chance of zoning map designation or chance to the City's Future Land Use
Mau?
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..
^ Yes LfNo: Are you representing anot-for-profit corporation or entity without special compensation
or 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 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 EXPENDITU S O MPENSATION DURING THE
REPORTING PERIOD. /I ~~ _
~ Signature of Lobbyist
I do solemnly swear that all of th for g facts are true and lcorrect and that I have read or am
familiar with the provisions contai ed ' Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of~M~i'~kKi~6AP~DE VIELLE ~~~~~~=
Sworn to and subscribed a Comm# DD0689339
This day of 20 8/26/2011
...s.uauuuuuni
Signature is Notary -State of Florida
Notarization of Lobbyist's signature
u Produced ID
Form of Identification
re'Personally known (PrinliPeL) ......................................:
XAVIER CAP DE VIELLE
r "'
Comm# DD06gg339
State of Florida, County o~ a E~res 6126/2011
~ Fbrld. -romrras~n., kic e
Sworn and subscribed below . .........................~„~~~~~~~~~
This _~day of ~c.~~s+' . 20 ~`]
Signature of i otary -State of Florida
Notariza on of Principal's signature
FOR CLER ' ll~ ONLY ~r
Annual Registration fee: [ ]Yes [ ] No Amount 5 ~i MCR # 0 Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobb ist\LOBBYIST fORM 05 Revised 1 08 04
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