Juana Quinonez/Rich Cochiarom 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 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 cormittee. 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)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) } (State) (Zip Code)
!Q-~Oi'~
TELEPHONE NUMBER: FA~c NUMBER:
I. LOBBYIST RETAINED BY:
EMAIL:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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:
II. SPECIFIC LOBBY ISSUE:
lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Y
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) _-5
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). SGT (GL ^l.~
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 ta'No• Are you lobbying on a present or pending bid for goods eauipment or services or on a
present or pending award for aoods, eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
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 snot-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 ~'~Vo• Are you representing snot-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 EXPE URES OR COMPENSATION DURING THE
REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all f the foregoing facts are true and correct and that I have read or am
familiar with the provision~co tained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Pri
VI. LOBBYIST IDENTIFICATION:
S~~Produced ID
Form of Identification
PRINCIPAL IDENTIFICATION:
^1 Produced ID
Form of Identification
^ Personally known (Lobbyist) ^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed b orn and subscribed before me
This day of ~~~~ ~J 4-rKERRYHERNANDEZ is day of , 20_
,~~vIy~COMMISSION # DD 626373
~~• .~ EXPIRES: May 3, 2011
Bonded Thru Notary PubNc Underwriters
Sign to e of P c otary- nature of Public Notary -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR LE 'S U E ~l .L`'I~
Annual Registration fee: [ Yes [ ] No Amou ai CR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.do Revised 1 /08/04