Arthur H. Hertz/Orange Bowl Committeem MIAMIBEACH
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
specrfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
BUSINESS NAME AND ADDRESS
30~ Saq~-I~{o3
TELEPHONE NUMBER:
EMAIL:
ip Code) ~ 3(3 y
r`O r'Y)
I. LOBBYIST RETAINED BY:
NAME OF PRIN AL/CLIENT:
~~®a
't 2 f'~1'1'I'- ~:~
(First)
i s,reS IY1C_ ~ 3 t 4 S'
umber and Street) (City)1
3aS5aa-ly8
(Number and Street) (City)
TELEPHONE NUMBER: FAX
3a/~
(Zip Code)
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:
II.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
U ~fl
c~..l'=
,,.
(M.I)
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City code section 2-482(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) An Financial, Familial or Professional Relations v
~ cry
rr ~.rr; ~ t V L~ ;-~ ~
~--
;~' Q,
. a.
~;
c=. cn
w
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
_~
~~
:~
~/.
7
tV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ O n
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). irl DYIf
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 1/J'No• Are you lobbvina on a present or pendina bid for aoods, eauipment or services, or on a
present or pendina award for aoods eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L~ No• Are you lobbvina on a pendina application for a Development Agreement with the City or
application for change of zoning map designation or chance to the City'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.
L~J Yes ^ No• Are you representing a not for-profit corporation or entity without special compensation or
reimbursement. .
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts a true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the i Beach City Co d all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ~ Produced ID
'~
L°
Form of Identification Form of Identification /
~
~
~e~
~~
~o ~ Personally known (Lobbyist) ~ Personally known (Principal) "
s ~ ~'.~~o
o m VII. SIGNATURE AND STAMP OF NOTARY: ~,~
w
N ~ ~ N
~
State of Florida, County of Miami-Dade
State of Florida, County of Miami-Dade
f
~ ~
v
~
~
,_,
~ °
. Sworn to bscribed bef re me ore me
sUbscribed be
Swor ~
~ ~
E o
~ This day of _, 2008 T s day of , 2008 N °o ~
V
Z,A°` Q,
om~x
z o w
Signature o I c of State of Florida
Signature b is Not State of Florida o °
~'`ab° Notarization of Lobbvi signature Notarization of Princi signature
° A,,//
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY IVG 0l~
Annual Registration fee: [ ]Yes [ ] No Amount Paid ~ MCR # Date Paid •--~^ ~~ `
Lobbyist Registration Form received and verified by:
<: ~IT-~ Revised 03/27/2008
V. SIGNATURE UNDER OATH:
m MIAMIBEACH
City of Minmi Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, voww.miomibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
CiyClerk@miamibeachfl.gov
~~'a'h~~ ~ ~ ~letfiZ
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.
Signature: Date: