Tracey E. Gallentine - Ameresco /V11/ DE/-\L 1 6,0
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 odificati. n
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or an city boa• '
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision- making pr•cess on =u' h
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committ =e. The e
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific excl : +ons. Pi a e
refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I) ;
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BUSINESS NAME AND ADDRESS (Number and Street) (City) State) ( p Code
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TELEPHONE NUMBER: FAX NUMBER: EMAIL: I
Please notify this office if your contact information changes: address, phone, or e-mail a dress:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (St (Zi• Code),
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) _-
Flli outthls section N principal Is a Corporation, Partnership or Trust [Section 2-482 (c)]
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTERE • T IN ....
SUCH CORPORATION, PARTNERSHIP OR TRUST: ""Cl <
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ii SPEC$FIC L OBBYyISSI E
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Issue to be lobbied (Describe'ir' detail): 1
iti CITY' AGENGIES/IND1VJE lALS oloot L' BBIED: Pursuant to City Code Section 2- 48.(g) Incl,r
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise tol
appearance of an impropriety with any City personnel sought to be lobbied — further, pursuant to City Code Section -
482(a)(4) Include a statement of any contractual relationship (paid or unpaid) from 12 months precedin, said 'C
personnel' commencement of service with the City to the present date, stating the general nature of e slrb e t
contractual relation.
A) Full Name of Individual /Title B) Any Financial, Familial or Professional Relation _ +; ip I
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A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): �I.
(Required). Y 1 2 ( OI jt?,�
The following information must be answered: J
1) Pursuant to Miami Beach City Code Section 2 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues ":
❑ Yes No: 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":
❑ Yes �No: Are you lobbying 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 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.
ED Yes l!!'l No: Are you representing a not - for - profit corporation or entity without special compensation or
reimbursement. .
i 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 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 EXPENDITURES OR COMPENSATION DURING THE REPORTING
PERIOD.
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I do solemnly swear that all of the foregoing facts are true an. " orrect and that I have read or am familiar with the
provisions contained in Sectio 2 the Mia i Bea City • • •e and all reporting requirements.
Signature of Lobbyist: . , /f?
Signature of Principal /Client: , v,,.....
LOBBYIST IDENTIF C ON: PRINCIPAL IDENTIFICATION:
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N o� ed D # C }' g-�T 5 (! 79i� _ r d ID i0 9 78' /09
g 2 Form of Identification Form of Identification
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,, • 0) U) s ❑ Personally known (Lobbyist) 0 Personally known (Principal)
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92 x tI SIGNATURE AND STAMP OF NOTARY: ' ! MY COMNNSSION # DD 879891
.� .,� EXPIRES: April 13, 2013
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`St e of Florida, County of Miami -Dade State of Florida, County of Miami J
.i.:'.,..-F.411 sti `°d :ern to and subscribed before me , Sworn An d subscriI ed before me
day of _ A'/V 20 This e y ofd .
Bonded Thru Notary Public Underwriters
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Signs ur - of Publi• N- - ry — State of Florida Signatur of Public '?' ry — State of Florida
1 Notari : tion of Lobbyist's s' nature Notariz: tion of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ 1 Yes [ j No Amount Paid $ A a -- MGR # 30 8SZ 7 Date Paid )z Z' `
Lobbyist Registration Form received and verified by a,
F: \CLER \$ALL \aFORMS \LOBBYIST FORMS \Lobbyist Registration Form 2010.doc D Revised 05/ 5/2010
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trA - MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl gov
CITY CLERK Office CityClerkCmiamibeac fl.gov
Tel: 305.673.7411 , Fax: 305.673.7254 -
LOBBYIST NAME: c 4,07,xri'
I understand that no later than February 28th of each year, I m st file the
following form, pursuant to Section 2 -485 of the Miami Beach City Cod-, 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 l ansmi`ted
to the Miami -Dade County Commission on Ethics and for code vi ion
evaluation.
In addition, once an issue I have registered to lobby on has been reso I ed,; I am
required to immediately notify the City Clerk's Office of lobbyist withdrawal in
writing.
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Signa Date: I
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Revised 09/24/2010 - REP •
F: \CLER \LOBBYIST \Expenditure. 8, Disclosure Forrn Itr.doc i !
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We are committed to providing excellent public service and safety to oll who live, work, and ploy in our vibrant, tropical, i storic
community.