Roman Jones/136 Collins Ave
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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 defined in any
manner in this section, 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 spedfically includes the
principal as well as any employee engaged in lobbying activities. The term ftLobbyistsW has specific exclusions. Please refer
to Ordinance 2004-3435.
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(State)
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FAX NUMBER:
EMAIL:
I. LOBBYIST RETAINED BY:
~ ~t (\I<;.
NAME OF PRINCIPAl/CUENT:
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(City) (State) (Zip Code)
NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [~~-482 (c)l 8S
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFlOARY: ~L ~ ~ ~
_~A-f\.)G1 <:; M, UO"- ""\
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECT(Y, A 5% OR MORE OWNERS~IP iNTEREST IN StJdt
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE: ~"-1. ~ (t-vL \ ~~ ~ ~V\
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Issue to be lobbied (Describe in detail): {
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A} Full Name of Individual/TItle
B} Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLATRATEOROTHER): ~
A) LOBBYIST DISCLOSURE: (Required) ~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required),
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions 8Y LobbYists On Procurement Issues":
2) Pursuant to Ordinance No, 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
thereof Entitled "Campaion Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions By Lobbyists On Real Estate Develooment Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPE~, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THEPRECE!>ING 'f:ALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDIT RES OR COMPENSATION DURING THE
REPORTING PERIOD.
I do solemnly swear that all,--Of-ttTe-foregoing facts are true and correct and that I have read or am
familiar with the provisions tontain~d in $ection 2-482 of the Miami Beach City Code and all reporting
requirements.
VI.
LOBBYIST IDENTIFICATION:
Signature of lobbyist:
Signature of Principal/Client:
PRINCIPAL IDENTIFICATION:
l-J Produced ID
lJ Produced ID
Form of Identification
~SOnaIlY known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Form of Identification
~allY known (Principal)
5 0 blic Notary State of Florida
Notarization of Lobbyist's signature
Signatur of Public Notary - State of Florida
Notarization of Principal's signature
~l; Came 50ImIer
. , My~00221814
':~ Expilel June 11. 2007
1lJCan1e5olmler
, , My CommIIIIon 00221814
~..~ ExpilelJunell,2OO7
FOR CLE~USE ONLY ~ ~ /
Annual Registration fee: [~ ] No Amount id - ,(/j) MCR #.9bq Date Paid tf 0 0
Lobbyist Registration Form received and verified by: I
Revised 02{10{04 F: E \MARIA-M\LOBBYIST\LOBBYIST FORM 04