Roberto Sanchez/Collins Corner\' J F iw.~ lfir:..~...9 ~'4~r f ..
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)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRwr^Ipni vi icnir
'..~_ per
(Number and Street)
f Z - 6 ~`(~
TONE NUMBER:
FAX NUMBER:
S~~,f~~ Sy/ i~ 1
(State)
~~ i7~e~ y~ ~ ~~
~ ~
(Zip Code) f~ /~
(Optional) l
out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~~.~ G /~-~/j~~ ~ ~~~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Descnbe in detail).
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-a82(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.)
Fun Name of Individual/Title
~ ~ ~' CG~~i SS~Gr'
'rte' ~~ 2y I ~ Cl~,~/~,>~
or Professional Relations
RATE OR OTHER): r
.~
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S. DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). S~ ~~ Ct n ~ `ki 4 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":
present or oendina award for goods, epuiament or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
j Real Estate Development Issues":
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~at, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Produced ID ~~ ~~~ a -77.c~ -}~j - X72_ ~
Form of Identification
^ Personally known
VII. SIGNATURE AND
Y:
State of Florida, County of Miami-D oo~i
Sworn to and subscrib before me ~,,~i~~is~B~
This l 7~ day of ~, 2008 ~ s'• oti ~y
Sighature of Public Notary -
Notarization of Lobbyist's
TO BE COMPLETED BY
Annual Registration fee: [ ]Yes [ ] No Amount Paid 3
Lobbyist Registration Form received and verified by:
F:\CLER\HATL\Farmsi~obb~4st Five,.,->-,;:,,, F ~=~:.ar•~
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
ignature of Public Notary -State of Florida
Notarization of Principal's signature
:LERK'S STAFF ONLY
"~ . MCR # 2 Date Paid 1
Revised 03/27/2008
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 Sect9q 2-4~ of the Miami Beach City Code and all reporting requirements.
+~' ~~
City of Miomi Beach, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fox: 305.673.7254
LOBBYIST NAME: ~~~'~ ~~ ~ -v
I understand that no later than October 1st of each year, 1 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.
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i~~~v~s~a o~roar2oos
Date:
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MiscetlaneousCash Receipt r~c~~-Mi~:.~s~r.~r;,~;~t~._ :~~~~~~ ~~~.~~
CITY OF MIAMI BEACH
No.
~ Cash C7 Credit Card Check #~~_
Received of ~
(THIS INFt7RMAT10N MUST BE COMP TED) Otfl~f Finance D1 ar
gy
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Account Numbs
Preparer. ~DLS ~~~ ~ per; ~~° EXT:~I~