Bryan P. Decortm MIAMIBEACH
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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 mod cation 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 princpal as well as any employee engaged in lobbying activities. The teen "Lobbylats" has speclflc exclusions. Please
refer to Ordinance 20043435.
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
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(Zip Code)
NAME OF PRINCIPAUCLIENT: '
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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FAX NUMBER: (Optional)
gut this section if principal is a Corporation, Partnership or Tru
• 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:
n:SPEC IC LOBBY SUE: , ~FP
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Issue to be lobbied (Describe in detail): ~"
ul. C1TY-AGENCIES'/.fNDIVID.UALS T.O B~E 'LOBBIED: Pursuant to City Code Section 2-482(8) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise 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 said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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(Last) (First)
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FAX NUMBER:
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HDUR4Y, FL74~T
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ ~ ~ 1 r y ~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). _ ~ µ ~ ~, ~ y ~ ~
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 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":
application for change of zonin4 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 but, shall not be required to pay any registration fees.
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~ ~ reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
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of Principal/Client:
IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
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ID ~l~~a~3~-~~5-`72-~~~-U ^ Produced ID ~~L~J...~6~-c~~7S - ~Z -~/7-a
Form of Identification Form of Identification
Personally known (Lobbyist)
~I. SIGNATURE AND STAMP OF NOTARY:
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a ~ ; ~ State of Florida, County of Miami-Dade
Sworn to an.~i subscribed before me
This ~~-~ day of ~, 2009
nature of ubl~ Notary -State of F orida
Notarization of Lobbyist's signature
^ Personally khown (Principal
State of Florida, County of Miami-Da ~~, ~fGf9 J~y~.
Sworn a~subscribe before me °"~'O' 2j`s ~~`~,
This~~_day of , 2009 q ,~ ?.,
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S' nature of Pub' Notary -State of orida "
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 21109.doc Revised 02/11/2009
I do solemnly swear th all of a foregoing facts are true a correct and that I have read or am familiar with the
provisions contained in Section -482 of the ft~iarfii Be~ich ' y C e and all reporting requirements.
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fox: 305.673.7254
LOBBYIST NAME: _
CiyClerk@miamibeachfl.gov
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I understand that no later than October 1st ofOctober l st of each~eor, 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:
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Miscellaneous Cash Receipt
CITY OF MIAMI BEACH
No. 29364
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^ Cash Credit Card ^ Check # _ _ $
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Received of ~ ~ ~~~ ~ '
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(THIS INFORMATION MUST BE COMPLETED) Office Finance Director
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Preparer• ~ Dept: ~ ~J _ EXT: