Jorge E. Dorta-Duque/100 21st St & 4299 Collins Ave
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 boartl or committee. The term
specifically includes the principal as welt as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
~O t2 i,~ u n ~ ~ ~ ~ ~.
NAME OF LOBBYIST: (Last) (First) (M.1)
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BUSINESS NAME AND ADDRESS° (Number and Street) (City) (State) (Zip Code)
LEPH E NUMBER. FAX NUMBER: t= 'T
1. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT.
H( 51NESS N ME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
~~d~ S~~_ v ~~
NUMBER:
Fill out this section if principal is a Corporation, Partnersh+p or Trust [Section 2-482 (c))
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: J~[~ ~ ~~ ~cjs
acog I~t'SS~1~ CN~rzC~S I~ ~ -sS ~ ~Q~ t'U~:~ss~ ScL.vt.~o(~a~o F ~=
• IDENTIFY ALL PERSONS HOLDING, DIRE TLY OR IND RECTLY, A 5 /o OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
U~2 (~I vc c ~ T'a iZ ~~ c
Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-asz(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
iK~~ y~ '~ ~ 1 V
V..-T~ ~ ~, ~,.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,•FLAT
RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) t •
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes ~NO: Are you lobbvinq on a present or pending bid for goods equipment 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 lobbvinq on a pending application for a Development Agreement with the City or
a~plicat~on for change of zomnq 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.
0 Yes ~ No: Are you representing anot-for profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
AV ArTnoro SST ~~ ~.~„ ,,,
I do solemnly swear that
provisions contained in Sr
the
of the
are t an rrect and that I have read or am familiar with the
Beach City Code and all reporting requirements.
Signature of
Signature of PrincipallLSlieai~_~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State o Florida, County of Miami-Dade
Sworn t and subscribed before
f day of ~ I 008
* +~ ,.
~5~~ re of Public No ary - tale of orida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
'~ Personally known (Principal)
State of Florida, County of Miami-Dade
Swpro, n subscribed b ore me
T '~ ~ ,~ p ;.$ 008
"' ~ Comm' Ion Ex'
.i o~`
w'g'
~~.
ignia a '- State of Florida
IVO ion of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ Yes [ ] No Amount Pai ~ . COQ MCR #
Lobbyist Registration F received and verified by: a. ~ _L~ ~D
F:\CLER\HATL\Forms tii.obby .. N,. St-;~ ~+: ,; F~....~.rtC•r
Paid
Revised 03/27/2008
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miami6eachA.gov
CITY CLERK Office
Tel: 305.673.741 I .Fax: 305.673.7254
CityClerk@m iamibeachfl.gov
LOBBYIST NAME: .~ G ~ ~ ~ ~d 2T~1-• ~ v ~. J
I understand that no later than October 1st of each Kear, 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
Miarrli-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 immeee~.icYt~ly notify the City Clerk's Office of lobbyist withdrawal in writing.
~~ S~ignatu~ D te:
Fdavisad 0?!04i200~
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