Octavio A. Campos/Vallejo Ganter
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.
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NAME OF LOBBYIST: _ (Last) First) ~Z~) , (M.q
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BUSINESS NAME AND ADD ESS (Number and Street) (City) (Sts ) (Zip Code)
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I. LOBBYIST RETAINED BY:
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FAX NUMBER:
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EMAIL:
NAME OF PRINCIPAUCLIENT: _
BUSINESS ME AND ADDRESS (Number and Street) (City) (Sts ) (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.1
SUCH CORPO TION, PARTN SHIP OR TRUST• ? o
II.SPECIFIC LOBBY ISSUE:
Issue to be lobbed (Describe in detail): ~ r
ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city cods section 2-as2(9)
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 72 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An
Fin
ancial, Familial or Professional Relationship
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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 LYNo• Are you lobbvina on a present or pending bid for goods eauigment or services. or on a
present or pending award for goods. eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chance of zoning map designation or chance 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.
C7 Yes ^ No• Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
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~f.~he Miy~ifii`Beachde and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
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LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
Produced ID ~ DL ~"~~ a ~ ~ ~ ~° ~ ~~~ ~ ~ Produced ID
Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
of Florida, County of Miami-Dade
i to and subscribed before rr~~
of ~L~t~ iii, 2008
of Public Notary -State of Florida
on of Lobbyist's signature
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Principal's signature
AFF ONLY
Si ure obbyist
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERr
A) LOBBYIST DISCLOSURE: (Required) ~~L~.4Z-`1
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 C~No: Are you lobbying 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":
QYes ~o: Are you lobbving on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change~o the Citv's Future Land Use
Man?
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
rnrporation 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..
^ Yes 57-iQo: Are you representing anot-for-profit corporation or entity without special compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 2~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CM OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEME
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURIN HE
REPORTING PERIOD.
Signature of
I do solemnly swear that all of the foregoing facts are true and correct and that I have
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and
requirements. ,--.
Signature of Lobbyist:
Signature of Principal/Client:
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read or am ~~t ~11"
II reporting Q p ~
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VI. LOBBYIST IDENTIFIC^AT~IO`N: (I I PRINCIPAL IDENTIFICATION:
Produced ID ~ L~ t..Jr i JQX`~u ~ ~ ~1V~ • [~ Produced ID ~ :t_ ~ ~ 71 v) "7 ~ ~l ~
a ~ -7 g, Fo of I entifi tin Form ~~ R ~~
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~..,.. - ~vIJUAM R. HATFIELD Np~y'ubNC • 31o1e of Fldlda
^ Personally known ( '- ~~ . Slole 6N y known (Pri ~i
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VII. SIGNATURE AND ~ifgNWon ~ OD ~7b299 ~'r~~n ~ ~ 37isZ99
ibnebd NaronelNotlaryAwn.
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State of Florida, County of Mia a e orida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before me
This I(e~" day of mtiic~f , 20 Q~ This /~ day of ~g//u''~ , 20 ~" ~
Signature of Public Nota -State of Florida Signature of Public Notary ='S a of Florida
Notarization of Lobbyists signature Notarization of Principal's signature
FOR CLERK'S, E~oNLY
Annual Registration fee: ]Yes [ ] No Amount Paid MC # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.d Revised 12/08/04
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~~~'t v ~~5
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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Signature Date:
F:iCLER1~~:r3~RYl~T1L.obbyst ReyisYration ~orrn 32708.doc