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Gustavo Matamoros/G. Matamoros 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: (Last) (First) (M.I) ~Si~c~nf ,~1- ~ ~o ~K a /~2 ~~ Miami Ft ~ la l BUSINESS NAME AND ADDRESS (Numbe and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: NAME BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip 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: n.SPECIFIC LOBBY ISSUE: ~~ Y 2oorJ die : ~.O ~~ Q~rhr1 irERS,~rR~+{ SUr3~,~ G S ~~~ Issue to be lobbied (Describe in detail): fwu~~(C ~~1 ~ ul. CITY' AGENCIES/INDIVIDUALS T© BE -LOBBIED: (Pursuant to City Code section 2~82(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) 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 OTHER): A) LOBBYIST DISCLOSURE: (Required) ~~ "~~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 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~"No• Are you lobbvinq on a present or pending bid for goods equipment or services or on a present or gendina 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 LB'No: Are you lobbvinq on a gendina application for a Development Agreement with the City or application for change of zoning map designation or change to the Citv'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. L~l Yes ^ No: Are you representing snot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON 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 RECEIVED Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICAY~6N: nPRINCIPAL IDENTIFICATION: dProduced ID l.. M351~ ~~ ?~ ("Jr~- ~2?~ V Produced ID~.. /~-1'35 ~-z~l -~`I j2~-O Form of Identification Form of Identification ^ Personally known VII. SIGNATURE AND STAMP State of Florida, County of Miami-Dade F o~GG__ Sworn to and subscribed pefore me 91'~~t+yB This ~2 _day of /'v1A 2008 ~ti``~s' s~o~ (/ gnature of ublic Notary - S to of Florida c,o~$~ Notarization of Lobbyist's signature ~' ^ Personally known (Principal) .;: . > :e r ~'p ~!/ State of Florida, County of Miami-Dade <`-{A'~~~"~B Sworn and subscribed before me ~Z'9c~S,`rsio~GZ, o q This day of M~, 2008 ~z•OOi ~p'~~ A~'~'~ O`~'~Qrr i ature of Pubic Notary -State f Florida s otarization of Principal's signature '~ry~. i~ TO BE COMPLETED B~'C1TY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid Lobbyist Registration Form received and. verified by: 6~4(^.l ~RU f1RRYTSTII ahhvic! Raniatrwtinn Fnr~n 27T~R.r1nn RPVieed n3/77/7AnR I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Sectio -48 f tt~lyliami ~ Code and all reporting requirements. City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: ~~~~~ ~~~~~. ~~~ ~~ ~" ~~ &Lt..(. ~C.~`-- I understand that no later than October 1st of each year, I must file the following forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues. 1) Lobbyist Expenditure Form 2) Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and for code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. JE- ~ ~® Sign ure: Date: F:ICLERILOBBYIS7tLobbyist Registration Farm 32708.doc