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Juan Carlos Toca/Toca Group 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 acliaor-, 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 welt as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please rdar tiD OMlnanee 2004.3435. OF (Last) (First) (~. (rVt.l) ~~rV NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: 1. LOBBYIST RETAINED BY: BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 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°h OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: a a -t7 ~O C' J A Full Name of Individual Title B An Financial, Familial or Professional Relationshi -~-~- r~2._._. Cc~t~1,c1Ls s ~ 11.,1"'Ct:lt'tf„ LVCSC3T I,~Ut: issue iv oe rworea tuescnoe rn aeian/: ~t~ ~ ~ ~ {-I S I ~ n ~~s ( ~ lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code seocion 2-4e2(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- 4s2(ax4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personneFto be lobbied.) 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 2488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": - - - - -- ---- .,~ ... ~ a present or pending award for goods eauicment or service 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": apclication for change of zoning mac designation or change to the Citv's Future Land Use Mac? 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. reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of Principe/Client: VI. LOBBYIST tDEN//T~~I11FICATION: // Produced IDf_~JC:.~~~-~G~~~~~ Form of Identification ^ Personally known (Lobbyist) 'I VII. SIGNATURE AND STAMP OF ~'!' ~o,o State of Florida, County of Miami-Dade o ~ ~-~ Swom d subscrib~¢-~ fore me < g This ~d ~y-of~J ~t , 2008 n. Sigrature of Public Notary -State of F Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: ~' ~~.~"d ~ Produced ID ~~L~d-~ 3-~(~ ~~~~j- Form of Identification TO BE ~ BY Annual Registration fee: [ )Yes [ ] No Amount aid ~ Lobbyist Registration Form received and verified by: F:\CLER\HATL\Porm: ,i.obbv-~' F.~-~t:,.°.. .. ~; c; ,:.,:.nr.: . ^ Personally known (Principal) W ~~ N State of Florida, County of Miami-Dade z Q T ~ Z ,~ .- .~ s Z'o a Sworn a$~ subsc~n~ed before me T is ~~P"`d f J L . o o '~ `~-' w t - aY o , 2008 ~ ~ o~ ~~ tel. W Si nature of Public Nota ~ 9 ry -State of Florida ~ Notarization of Principal s signature ~„ LERK'S STAFF ONLY '~qv..•~h MCR # Date Paid ~ D i lC ©~ a.i ced /17 7AA 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 Section 2-482 of the Miami Beach City Code an_~ all reporting requirements. ~. City of Miami Beach, 1700 Convention Center Drive, Miomi Beoch, Florida 33139, www.miomibeachfl.gov CITY CLERK OFfice CityClerk@miamibeachFl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: 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 imam diately noti t Jerk's Office of lobbyist withdrawal in writing. Signature: l~l~visaa o2roa;zoos Date: ,.