Michael E. Bath - National Gay & Lesbian Task Force Foundation it\1
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City OfMiami 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 nou, by o principal who seeks to encourage the pooaoge, defeat or
modification of any onJinanoe, nomo|ubnn, action or decision of any commissioner-, any oction, deo|o|on, 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-making process on such oction, decision or recommendation that nonaaeoob|ywill be heard or reviewed by the city
oomm|oo|on, or a city board or committee. The term specifically includes the principal as well as any employee engaged in lobbying
oct|v|doo. The term"Lobby|mts"has specific exclusions. Please refer to Ordinance oo04'3*35.
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NAME OF LOBBYIST: (Last) (First) (M.1)
BUSINESS NAME ANPI ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE.,..,..^.`: ....,..,..^.`: ^.,~.^: ^~~�
Please notify this office ifyour contact information changes:address,phmne� mre-mail address.
/. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIEIT:
BUSINESS NAMEJAND ADDRESS (Number and Street) (City) (State) (Zi Code)
�
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMA1:(Optiona
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:
x8P8 WIG LOBBY ISSUt'.,
C.
Issue To be lobbied(Descte in detail):
Ill.PITY,AGENCIESANDIV.11 DUALS TO-113E,10BBIED:
Pursuant to City Code Section 2-482(a)(4)include the commissioner p,personnel sought to be lobbied,and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or narsvnmm from 12 months nrecoumm such person's
commencement of service with the city to the present date,stating the general nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
c (A X
Pursuant City Code Section registrant shall uo required to state the extent ov any business,financial,familial o,professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought tobo lobbied aoidentified on the lobbyist registration form filed.
Sec 2-482(g)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) (�
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPEN AT N):
(REQUIRED). c, c 't,.I— C_ G �1
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues":
_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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes o. 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 Section 2.482(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.
-�No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 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.
Signa ure of Lot byis
I do solemnly swear that all 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 the Miami Beach City Code and all re ring requ*ement
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Ft �.9/IIC I J L G _ roduced ID rL J/RI.tleR .S `IG •
Form of Identification Form of Identification
Personally known(Lobbyist) „�o Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY: �.� C6 tea'
�Q 144
State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade
Sworn to and subsc' ed b�for� ``'D Sworn a d subscribe bed me S c�
This da of /�/ 1 m° This ay of 07l_ 2012 ` a'
Signature o is Notary ate of Florida .;eTP;; Signature ublic No ry– ate of loridati �J!'°'o=
Notarization of obbyist's si ature Notarizatio of Prin al's signature
TO BE COMPLETgQ BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ( ]Yes[ ]No Amount Paid$ MCR# ` a Paid
Lobbyist Registration Form received and verified by: ti
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Formrevised 5-30-2012.doc
)isbra,don For,,mdoc Revised 04/27/20
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.rriiamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk@mlamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME:
I understand that no later than February 28 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, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d),the City Clerk shall notify any lobbyist(or principal)who
fails to timely file a Statement and in addition to any other penalties which may be
imposed as provided in Section 2-485.1, a fine of$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
ullt,
Signatu Date:
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Forrnrevised 5-30-2012.doc