James MacKenzie - La Gorce Country ClubI
~~ m MIAMIBEACI~
. ~ .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-makirig 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.I) .
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:BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: ~ FAX NUMBER: EMAIL:
I. .LOBBYIST RETAINED BY: .
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. Ni4ME.OF PRINCIPAUCLIENT: ~ ,
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BUSINES® NAM~ND A~~ S~ (Number and Street) (City) (State) (Zip Code)
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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:
~I.SP.EC'IFIC LOBBY ISSUE:. 331 ~®
Issue to be lobbied (Describe in det~}~: ,
nl. CITY AGENCIES/INDIVLDUALS 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. 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 ~,
personnel' 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 r
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FL,gl~r~,~
RATE OR OTHER): ,~
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A) LOBBYIST DISCLOSURE: (Required) ,: ~ ~ : , ; . ~ C~~G~~,~'~ '~ .~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~n~
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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 ~!_f No: Are you lobbvinq 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
Reat Estate Development Issues":
^ Yes .,idJ N0: Are you .lobbvinq on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change 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 snot-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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No: Are you representing a
reimbursement. .
V. SIGNATURE UNDER OATH:
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ON OCTOBER 1sT 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 CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDI R S OR C ENSATI N DURING THE .REPORTING
PERIOD.
re of Lobbyist
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I do solemnly swear that al t e fo
provisions contained in S tion 482.
acts re'true and correct and that'I have read or am familiar with the
ami~each City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Cli,~nt:
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PRINCIPAL IDENTIFICATION:
LOBBYIST IDENTIFICATION:
Produced ID ~~L~E..J~~~~.- LI~(o-~5- `a~la`D ^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
tate of Florida, County of Miami-Dade
worn to and subscribed before me
his day of , 2010
~~
Signature o Public Notary - State o Florida
Notarization of Lobbyist's signature
Form of Identification
Personally known (P i
~.1~ ~ Notary Public State of Florida
Mabel Padron-Hernandez
c, ~ My Commission 00930358
~~ M1~ Expires 12/18/2013
State of Florida, County
Sworn a d subscrib before me
~~his of ~ , 2010
Signatt.~ of'Ptlblic Notary -State of Florida ,
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ . .Yes [ ] No Amount Paid $ CFA #
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc
suv/-~~r-6'~~ e
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Date Paid
Revised 05/05/2010
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Ciiy of Miami Beach,'1700 Convention.Center Drive, Miami Beach, Florida 33139, www.miamibeachfl:gov
CITY CLERK.Office. ~ CityGlerkC~miamibedchfl:gov ' .
Tel:- 305.673:..741 1 ;Fax: 305.673:7254. ~ ,
a4cknowledgement of:fines/suspension from lobbying for failure to
c®mply wi d> City of Miami Beach lobbying Laws
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. - LOBBYLST NAiME: ~~~ ,:
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- ~ I understand that no-later thc~n~ Octobee~ 1st of each year, lobbyists subject to hobbyist ~ -
..
.: registration requirements shall ;,submifi to the city clerk a signed' statement .under -oath
' - listing, all lobbying 'expendi ure , as well: as compensation received, for the preceding
calendar year with regard t~~ the specific :issue on which .the lobbyist hasbeen engaged
to; lobby: A .sta ement shall' ~'be fil:ed even if there have been no~ expenditures or `
compensafion during the r~port'ing period. The statement shall list, in detail, each -
. ~ expenditure by category, including .food and beverage, entertainment, research;
communication, .media advertising; publicdaions, travel, lodging and specia events.
:failure toy timely #ile the expenditure and fee disclosure report vvial result,
in a fine of $50.®0~ per _day. Any .lobbyist. who fails to file the required
: ~ .expenditure report by December 1, sha11 automaticall be sus ~ ended
Y p
rom o b en u
i ~ Y ntil all fines .are paid, un ess the #ine has been appealed
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t® the Miami-®.ade County Commission on Ethics :and Public Trust. In. the
event a lobbyist fails to either file the report and/or pay the assessed fines, the Clerk shall
notify the Miami-Dade County Commission on•Ethics and Public Trust:
Inadclition once an issue i-have registered~to lobby on has been resolved, I am required:
to' immediately notify the City C1erk's Office of lobbyist withdrawal. in writing.
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