Charles A. Citrin~ N
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City of Miami Beach Office of the City Clerk r_-_
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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.
NAME OF LOBBYIST: (Last) (First) (M.l)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: '"'c FAX NUMBER: EMAIL:
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT: _ _
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [~Se/ctio~,nnn2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: (~.~ / ~ r'1P ~ ~ S ~-/ + ~- 1 J~~t, I/tOy
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:``~fj~~ ~ ~? ~,~ J ~~~'• v~-~9~~~;1 /~{ /' ,
u.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
Ili. Li 1 `i /^°i~~~°iC~~SiI~'Svl:ll~.[.;~''~L~J T~ ;/E I_Ocg. BIr=~: Pu~•se:ant tc City Code Section 2-~'a='(9) inc!::d°
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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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) o JF ~ ~•~ ~ ( t ?" T.,r .-- l5t_i _ L_°~____
----------------------------
B) PRINCIPAL'S DIS~kOSURE (OF LOBBYIST COj+(1PENSATION):~
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(Required).------ -c:IVt_ ~_~>: D-- ~-~----=~-~L'~,!i~%-_1''tw..a~' il~!---Y-~~~'(-(~=- -
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The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions ~y'Lob~sts
On Procurement Issues": ~ .-
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LYJ Yes ^ No: Are you lobbying on a present or pending bid for goods equipment or services, orron a ' ~ ;-'~
present or pending award for goods equipment or service? - .F- ~~~
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyi~s On-o
Real Estate Development Issues": ~ `~~
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3)
Pursuant to Miami Beach City Code ?_-484 (h) ~~ny 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
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 Sectio~t 2-482 of the~liami F~each City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: ~~~~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to an subscribed efore me
This __day of _ ~_, 2009
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
^ Produced ID ________
Form of
Personally known (Prii
State of Florida, County of Miami-Dade
Sworn and subscrib~dn be re me
Thi ____ ay of %JI1~ _, 2009
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Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF,QNLY
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ON OCTOBER 1ST OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov c-~
Tel: 305.673.741 1 ,Fax: 305.673.7254 --° °~
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LOBBYIST NAME. :.
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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:
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