Alexander Heckler/Jeannette Varela?~ MIAMIBEACN
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:
~~ ~.~ ~~
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
~ .~
(Last) (First) (M.I)
~ pp\ ~ ~° "~' ~ ~ ~ t
~- !
(Number and Street) (City) (State) (Zip Code)
~~
FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY;
l~~ ~ ~ i i ~ A 1~. t c...~~
NAME OF PRINCIPAL/CLIENT:
,,
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Z~p 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 CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
11. ~rC~trt~ LUtStfY 155Ut; ~ -' J C~)~~~
L S~- Z.or~ ~~.
1 '`SA
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED;
A) Full Name ofIndividual/Title B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
~~
A) LOBBYIST DISCLOSURE: (Required) ~ ~~~ , ~ ~ ~~`~ ~ ` ~~
B) PRINCIPAL S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ ~ ~ ~ ~ ~ ~`' ~ ~ ' f'
r
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 No: Are ou lobb in on a resent or endin bid for oods a ui ment or services or on a
` present or pending 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 ~ No: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change 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 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 „~No: Are you representing anot-for-profit corporation or entity without special compensation
or reimbursement. .
V, SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIS SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYIN PENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDI G CALE DAR Y AR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN N EX ITU OR M NS T N DURING THE
REPORTING PERIOD. n I
Signature of Lobbyist
I do solemnly swear tha all f the foregoing facts are true and correct and that I have read or am
familiar with the provisio s co t • ed in Section 2-48 f t mi Beach City Code and all reporting
requirements.
Signature of Lobbyist:
e~
e;
Signature of Principal/Client: ~'
.--
VI. LOBBYIST IDENTIFICAT ON: ~'~~,,~~~ PRINCIPAL IDENTIFICATION:
_ed ID pi~ ~ ~• _ q j/
1, ~ . --~, ~ ~uced ID ~ _ w ^-~~
" Form of Identification Form of Identification
Personally known (Lobbyist) ~J Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade ~ State of F ~
Sworn to and subsc Sworn an '~~~ ''pi'g' d
.~ ,;~~.~ ~ ~~ B~I~fERNANDEZ ~.; ~ . .~; .~ ,1~ ON # 26313
i ~~
This ~ day -~~ ~S10N#DD626313 This ~' ,.~``` ~~ ~ ~~s~~3, 11
*~ - ~
:*=
•tt ,~1~ OF flp`~.
' ' ' EXPIRES; May 3, 2011 '~' '• •' Q' ded rh otary Pub Underwr~ers
J ~, ~ ~ ~ ~• ~, prided Thru Notary Public Underwriters
Sig~iature o P lic ~ `~`''~" Signature of P is Noted e of ida
Notarization of Lobb fist's si nature ~ '~''`~~
y g Notarization of Principal s signature
FOR LESS l~S~ ONLY ; ~ ,--~ ,
Annual Registration fee: [ ~~ Yes No Amou P ~'id L- ~ ~ ~% MCR # ~ ~ ~'~ D P i ,_ 7~ ~ ' ~~
] [ ] .s~ ,~._ ate a d ~ ~`
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM c - ,~ Revised 12j08/04