Andrew Frey/Key International Dev. Inc.m 11AMBEACI
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
_obbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
x modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
;ity Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time period
if the entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the
;ity commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged in
obbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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SAME OF LOBBYIST: (Last) (First) (M.I)
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3USINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
1"ELEPHONE NUMBER:
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FAX NUMBER:
EMAIL:
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LOBBYIST RETAINED BY:
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3USINESS NAME AND ADDRESS (Number and'Street) (City) (State) (Zip Code)
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1"ELEPHONE NU BER: FAX NUMBER: (Optional) EMAIL: (Optional)
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
=ill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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ssue to be lobbied (Describe in detail): ~
(~~~. Ace~uolLy usE CiA~l2,s pN0
:n. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: ~~ S Tai.' r iarv rs ~~ Rp r Ot~~ ~ t c~
4) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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V. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
?ATE OR OTHER):
',) LOBBYIST DISCLOSURE: (Required)
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3) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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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 L~Y1Vo: Are you lobbvino on a present or pending bid for goods, equipment or services, or on a Dresent
or pending award for goods, equipment or service?
?) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
7Yes C~'IVo: 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.
7 Yes Ga-IVo: Are you representing anot-for-pro£t corporation or entity without special compensation or
reimbursement. .
SIGNATURE UNDER OATH:
~N OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
DECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
3E FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING
" Si§nature of Lobbyist
do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
xovisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: ~
Signature of Principal/Client:
/I. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
- Produced ID ~ Produced ID
Form of Identification Form of Identification
Personally known (Lobbyist) 'Personally known (Principal)
/II. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to d subscr' d before me Sworn and subscribed before me
This ~_day o ~1/JY~t ~. ,., ~~:~~~~.~°~ is day of r' ~ r 20 , ,,s~~,~.,,
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FERNANDEZ -~ ~~'
P"'~,. C~ E
SILVIA FERNANDEZ
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z w~[ss[oN # DD3[291a _ _' :__
"~ `-~" ~ ~'-~-- ~ `~ - ` ~ MY COMMISSION # DD 680872
EXPIRES: September 23, 2011
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Signature of Public N vary - Sg e's ~rida Naarv~scow,~nssoa E.o" gnature of Public Notary -State. ""' ~
1- IX13-dOTe1R`~ BondedThru Notary Public Undenvmers
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Notarization of Lobb fist's si Via, otarization of Principal's sign
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
annual Registration fee: [ ]Yes [ ] No Amount Paid $ ,`~ `~ 0 t7
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VICR # ~ `e' '' ~' `~ ~ Date Paid _~~ ~ I ~.. ~-' ~'r~"
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_obbyist Registration Form received and verified by: ~-~--4.-~ z--~ ~~-t.~ ~~ ~,~ ~}
Revised 02/04/2008