Aaron B. Perryx' r
~ ~°~ ~ ~~f~ti:
~°c~~i~'~''~',,~r~~
_.. ~ `.... k ~..
City of Miami Beach Office of the City CIer~D~9 S~~' 30 ~~; ~~: j 3
1700 Convention Center Drive, Miami Beach, FL 33.139
l~a~ ~' C.L.E. i~~.y';7 l1;' ~ i~~r_
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 cky board or committee. The term
spec~cally includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435. ~ ~?.,
NAME OF LOBBYIST:
TELEPHONE NUMBER: FAX NUMBER:
1. LOBBYIST RETAINED BY:
NAME OF
BUSINESS NAME
(Number and Street) (City) (State)
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 IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
V
u.SPECTFIC LOBBY ISSUE
Issue to be lobbied (Describe inlietail): -
in. CITY AGENCIESYINDIVfDUALS TO BE LO.BBtED: Pursuant to City Code Section 2-482(g) 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 Clty Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 72 months preceding said Clty
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE
The following information must be
1)
~'
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
2) Pursuant t iami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real E to Development Issues":
application for change 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.
reimbursement. .
SIGNATURE UNDER OATH:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
~L~~6CQ'-L~c~Z -~i' 6-d
r Produced ID -l7
°° ~ ~ Form of Identification
~g^
~ ~ $ ^ Personally known (Lobbyist)
w
~€ VII. SIGNATURE AND STAMP OF NOTARY:
m State of Florida, County of Miami-Dade
~'V~,, Sworn to and subscribed befor me
~~• ~ ~''~ This ~t•• day of 2 009
Signature f Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
Produced ID ~~Cx~-oo2. ' 6~-~ <lo ~U
Form of Identification
^ Personally known (Principal)
gR
'~ -~
State of Florida, County of Miami-Dade
Sworn and subscribed bef re me `~~
This ,day of , 2009 ° ~ ~ a
:~
~ '~~
m
Signature of Public Notary -State of Florida 's°y-,,
Notarization of Principal's signature =~~~,:~,
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY 'ON - ~O{~t ~'
Annual Registration fee: Yes [ ] No Amount Paid $ .~ WICf~t # ~--- Date Paid A
Lobbyist Registration Fo m received and verified by: ~~~~ G Fhb Q ( i
~:1CLER\$ALL~aFbRMS~LQS~YZS'r FURMS1Lobbyist Registration Form 25.2r15,tfoc ~,, ,,, ,f--~ ReViSed 02/lll
~~~~~~/ .
present or pending award for goods equipment or service?
,~-~'"
I do solemnly swear that all of the foregoin~q~a re tr nd c ect and that I have read or am familiar with the
provisions contained in Section 2-482 ach City Code and all reporting requirements.
Signature of Lobbyist:
m
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME:
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 J 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 lob~ist withdrawal in writing.
S
Date:
F:IGLERIL{)Bl3YiSTlLobbyist Regisiratian ~or'nrs 32708.doc