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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 modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city board or
commlttee; 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 inGudes the principal as welt as any employee engaged in lobbying activities. The term "Lobbyists" .has specific exclusions. Please
refer to Ordinance 2004-3435. /~
NAME OF LOBBYIST: (L t) (First) /n~
~ e / / _ ., n ~ ~- .. ~'(f%~) man /' ~~~il
611SINESS NAME AND ADDRESS (Number and Street) (City) (State
(Zip Code)
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TELEPHON NUMBER: FAX NUMBER: Fnnau
Please notify this office if your contact information changes:
LOBBYIST RETAINED BY:
phone, or a-mail address.
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NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out tttis
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or
• 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:
u.SPECIFIC LOBBY ISSUE: r/l~' r~u ~
Issue to be lobbied (Describe m detalp:
Ill. CITY AGENCIES/INDIVIDUALS 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 Clty
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
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~~ ~~~~y~ex~Q~K~f'LLJ
(Required}.
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 I~NO: Are you lobbvina on a present or pendinq bid for goods equipment or services or on a
present or pendinq award for goods, equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitied "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~/fVo: Are you lobbving On a pendinq application for a Development Agreement with the City or
aAplication 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.
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA'
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Produced ID t^y~J'~•~$ll -:53-- g77-U
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
PRINCIPAL IDENTIFICATION:
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~roducedlD Cy~~J-v~~~ 'J`~3-g~~-U
////// Form of Identification
State of Florida, County of Miami-Dade
Sworn to and subscribe efor me
This ~ ,,day of , 2010
LQ~' ~--~
' ~ '' Signa ur of Publi N ary -State of Florida
Notari tion of Lobbyist's signature
t i TO BE COMPLETED BY CITY
Annual Registration fe] Yes [ ] No Amount Paid $!L
Lobbyist Registration F eceived and verified by: _~~
F:\CLER\$ALL\aFORMS OBBYIST FORMS\Lobbyist Registration For
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed bef re me
This day of , 2010
Signat e of Public Nota -State of Florida
Notari ation of Principal's signature ~ ~
:LERK'S STAFF ONLY ^ / „~
~~ Date Paid
2010.doc
Revised 05/$5/2010
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Signatur%f obbyist
I do solemnly swear that all of the foregoing facts are true alnd correct and that I have read or am familiar with the
provisions contained in Section 2-4~2.,Qf the Miami Be~ctii City Code and all reporting requirements.
m MiAMIBEACH
City of Miomi Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miam ibeachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME:
Cl/L>'
I understand that no later than October 1st of each year, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a .signed statement under oath
listing all 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
compensation during the reporting period. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE TO TIMELY -FILE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO FILE 'THE REQUIRED EXPENDITURE REPORT BY .DECEMBER 1, SHALL
AUTOMATICALLY, BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADS 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.
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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Signat re• Date: