Robin J Schwartz - Aqua Foundation for Women •
MIAMJBEACH
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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 prindpal 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 derision, 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.
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NAME OF LOBBYIST: (Last) (First) (M.I) fll 4 4 '
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) ! (Zip Code ) 33f77
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if: your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY
NAME OF PRINCIPAUCLIENT:
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 [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:
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Issue to be lobbied (Describe in detail):
III.
CITY dirr AGENCIES /INDIVIDUALS TO 'BE L ` BBIED Pursuant to City Code Section 2- 482(9) 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
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBB1(1;COMP, Et TION):
(Required). At T (A---e (Jo ' 1
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":
0 Yes o: Are you lobbying 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
Real Estate Development Issues":
0 Yes No: Are you lobbying on a pending application for a Development Agreement with the City or
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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 a not-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.
Yes 0 No: Are you representing a not-for-profit corporation or entity without special compensation or
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V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL rt.S COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALEN 0 ' - E — STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES 0 - 2 1 P ' 5 0 - k G T / REP_ORTING
PERIOD.
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I do solemnly swear that all of the foregi - • - s are true - l eoirrrect an. at I have read or am familiar with the
provisions contained in Section 2-482 of he It 1 Be-- ity 'ide and - reporting requirements.
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Signature of Lobbyist: 41111111112111WAIIIIIIV
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Signature of Principal/Client: /411W40!4/Ittar- ..
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LOBBYIST IDENTIFICATION: a R1 - 1j ,..NTIFICATION:
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• roduced ID .6-.-_,d..- /Du 40 ork ' ( I / - U 0 Produced ID S 63 730
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Form of Identification Form of Identification
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0 Personally known (Lobbyist)
0 Personally known (Principal) „svg ,,,,,,,,
ISABEL SATCHELL
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SIGNATURE AND STAMP OF NOTARY: , e41.-,- . A: EXPIRES: April 13 2013
Bonded Thru Notary Public Underwriters
I StatO „ , of Florida, County of Miami-Dade State of Florida, County of Miami-6 - •e
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'Swdrn to ansubscribed before me Sworn and subscribed before me
This, / .- d of • , 2110 This / 5 rda of De _ , 2010 '
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Signature of P blic Not- State of lorida Signature o Public Not ry - State of Florida
Notarization .f Lobbyist's signature Notarizatioh of Principal's signature
zi TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: I i l Yes [ I No Amount Paid $ 0 M R # . Date Paid /Z/ i 4)
Lobbyist Registration Form received and verified by: I I ir /
F: \CLER \ $ALL \aFORMS\ LOBBYIST FORMS \ Lobbyist Registration Form 2010.doc ?NOWT .--r Revised 05/05/2010
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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
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: NAME: 1 13t A) S W 2
I understand that no later than February 28th of each year, I must file the
following form, 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 and Compensation 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:
Revised 09/24/2010 - REf?
F: \CLER \LOBBYIST \Expenditure 8.: Disclosure Form Iu aoc
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community