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LOBBYIST REGISTRATION FORM
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
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 lobbyin ivities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
OF LOBBYIST:
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S NAME ND ADDRESS (Number and Str e) (C' ) (State)
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INE NUMBER: FAX NUMBER: F
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1. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT,n ,,r~ `
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BUSINESS AME A DAD E S (Number and S r~'f) \ (City) (State) (Zip Code)
BER: FAX NUMBER: (Optional) EMAIL:
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:
u.SPECIFIC LOBBY ISSUE: `t , ~
Issue to be lobbied (Describe in detail):
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city Code section 2~18z(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
RATE OR OTNER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATI
(Required). _ `~I)~y~~
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 L~(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 Deve{opment Agreement with the City or
~ptication for change of zoning map designation or change to the CitV's Future Land Use
M8p?
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, shalt register with the clerk as required by this
~( section but, shall not be required to pay any registration fees.
~J Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: % (~'" C/`--t
Signature of Principal/Client: '~r
Vt. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTy~IFICATION: ,~
Produced ID ~i c.~J ~'~ ~- ~ tProduced ID 1 (~- ~ti t-~ ~ ~-
Form of Identification Form of Identification
^ Personally known (Lobbyist) ^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
'""""° Claudia P. Elorz ,~°"~ "''~- Claudia P. Elorza
State of Florida, County of Miamg P~!a~% Mate of Florida, County of Miarrp-~a ~L~%Commission #DD565Q99
Swor to and subscribed efore=r :e :Commission #DD56509~wo n and sutrscrib d befere ~~~ ire5; TUNE 18, 2010
Thisv~~ day of :9 • Expires; JUNE 18, 201(jhi .day of _ '• . • ~r; P
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i ~ i" ~•, s'~0De1~6o .. WVdW.AAR~N~lE1TARY,.^.orri ()~ ;~ r '~d~~F.~«~°, WV•IlN.;4ARQr1N07A":`(.!:,:;
Signature of Publi ry -State of Florida Signature of Publi State of Florida
Notarization of Lo 's signature Notarization of P 'n al's signature
TO BE COMPLETED BY CITY CLERK'S STAFF O Y
Annual Registration fee: [ ]Yes [ ) No Amount Paid $ CR # ~ Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\NATL\Form~,.obby ,^ s<c-c.-.~- ,:.,~, c~.:...;.nr.: Revised 03/ 7/2008
I do solemnly swear that all of the foregoing ,fdcts a true and correct and that I have read or am familiar with the
provisions contained in Sectio~2 o~ie Miami B Bch City Code and all reporting requirements.
City of Miomi 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:~~~-~Py~O~'~~
~~~~~
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.
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