Amy B. Boulry - Calvary Chapel of Miami Beacht ~~ .~ .. .
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" ~ ,City of Miami Beach Office of the :City Clerk ~ °' ~ `
-, ~~`i 1700. Convention Center Drive, Miami Beach, FL' 0 ~,
LOBBYIST REGISTRATION FORM
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Lobbyist means all persons employed or retained, whetherpaid or not, by a principal who seeks to encourage the' as'sage~-defeat orvna'di~c~tiob~~f.
• any ordinance, resolutibn, action or:decision of any:commissipner; any action, decision, recommendation dithe City Manager or any city board dr
'. "committee; or any action, decisioh or recommendation of any city personnel-during the. time period of the ehtire decision-making process on such .: '
action, decision or-recommendation that foreseeably will be heard or reviewed by the citycommission, 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
referto Ordinance2004-3435.
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s ~ NAME. OF LOBBYIST: ° . ~~ ' (Last) ~ ~ (First) ... {M.I) '
BUSINESS AME AND ADDRESS . ° .(Number and Street) " (City) (Statep . ' -. ,..(Zip Code)
~. T,ELEPHO NUMBER: FAX MBER: EMAIL:, "
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I. LOBBYIST RETAINED BY: ` ~ ~~~
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.:':NAME OF PRINCIPAUC,LI T. ,
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,BUSINESS NAME'AND ADDRESS ~ , Number.and Street )
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" ,TELEPHONE NUMBER: FAX NUMBER: (Optional) - .EMAIL: (Optional)
iI:SPECIFIC :LOBBY 1 SUE: ~ `~ "
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., Issue to be lobbie (Describe in detail): - • ~ ~ .
~' nl. CITY-AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuau~t to,City_Code Section 2-482(g) include
a statement. of the extent of ..any business, financial, famlhal;~,pr'ofessional 8r•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 generai nature .of the subject
contractual relation. .:;; ~~
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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, FL°AT
RATE OR OTHER): _ ~~
A) LOBBYIST DISCLOSURE: (Required) !~'~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): '~
(Required). [ ~ ~~~~,
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The following information must be answered:
?) Pursuant to Miami Beach City Code Section 2-488 Entitled-"Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes L~'NO: Ate you lobbvina on a rfrPCant nr nanrlinn hirl fnr nnnrlc nn~ ~i.,..,e..l ,.....;. ....:....:. .... _.~ .
present of 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":
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^ Yes ~fo:. Are you lobbvina on a_pendinq application for a Development Agreement with the City or
application for change of zoning 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. .
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Signature o obbyi t
I do .solemnly swear that ali of the foregoing facts are true and correct and that I have, read or am familiar with the
provisions contained in Section 2-482 of ~he Miam~ ch City,Code,and all reporting requirements.
Signature of Lobbyist: CLL1..~Ar1 ~"'~ \~(
Signature of Principal/Client:
UL ,~ L/O'~BBYIST IDENTIFICATION:
L~-'Produced 1D ~, U~~ ~:'~ ~Q~`E_.
~~~ ~~ ~~~~Form o~y~/~en{(~fy~(j/c~ation/~
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~' ~ ~ a ^ Personally known (Lobbyist)
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"' ~ w Z VII. SIGNATURE AND STAMP OF .NOTARY:
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~ "';; State of Florida, County of Miami-Dade
m Sworn to and subscribed efore me
;~:*'.':Y~~, This ~,r~ day of~~~~, 2010
'Signa~e bfPublic Notary -State of Florida
Notarization of Lobbyist's signature
TO BE
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PRINCIPAL IDENTIFICATION:
roduced ID ~~~~ - ~~~VJc~-~/~-~ '
Form of Identification
^ Personally known {Principal)
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State of Florida, County of Miami-Dade ~ N N s
Sworn and subscribed before me ~ g. ~ 2
This c~S day of /~ ~ , 2010 ~' i3 X~
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Si nat e of Public ota
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Notarization of Principal's signature °
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BY CITY CLERK'S STAFF ONLY ~
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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 2010.doe 'Revised 05/05/2010
V. SIGNATURE UNDER OATH:
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r4. Gity of Miami Beach,.1700 Convention Center Drive, Miami Beach, Florida 33139, www%.migmibeachfl.gov
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CITY CLERK Office CityClerk@miamibeachfl.gov ''
Tef: 305.673.7411 ,,Fax: 305:673.7254 .-
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/~cknowledgenent of fines/suspension .from `lobbying for failure to
comply with City of iWiart~i Beach. lobbying .Laws - -
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®BBVIST I~IAiN1E: ~';.-~'~~~ - .
' I understand that no later than ®ctober 1st of each yetar, lobbyists"subject fo lobbyist
registry ion requirements: shall submit to the- city clerk a_ signed statement under. oath
listing. al'i lobbying expenditures, as .well as compensation received; for the. preceding
calendar year with regard~to the specific issue on which the lobbyist .has .been engaged
' ~ ' to lobby. A statement shall be filed even ~ if there_ have .been no expenditures or
~, comperisation during. the reporting period. The statement shall list, . in detail, :each
- expendi ure by category, including ~ food.. and beverage,,,. entertainment, -research, ,
communication, media_ advertising, publications, travel, lodging `and p'ecial events.,
Fdiluire to timely fi6e. theexpenditure ®nd fee ,disclosure report will result
in .a fine of :$.50.00 :per day. Any lobbyist who fdils to file the required
expenditure rep®r# by ®ecember 1, ,shall .automatically: be suspended
from lobbying until all fines .are :paid, unless the fine has been appealed
to the Miami-Dade :County Comaw9ission on Ethics and ~Rieblic Trust. ln: 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. `
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''In addition, once an, .issue l have registered to lobby on has been resolved; ~l am required.
to. imrimediately notify th,e City Clerk's Office of lobbyist withdrawal. in writing.
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Signature: - . ' Date; ~~
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