Marcia Zerivitz/Jewish MuseumN1ia:mi~Scoch ~
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 committee; 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 includes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please rofer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First)
BUSINESS NAME AND ADDRESS (Number and Street) (City)
7,2.
TELEPHONE NUMBER: ! FAX NUMBER:
(M.I)
(StatE) (Zip C6cle)
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EHA~L:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street)
TELEPHONE NUMBER:
(City) O' ' (State) ' (Zip Code)
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' L~/~/~j~ .~.,..~ ..... ~ 7'7__ · ·_ '7- _
. / ' c; ~,~ ~-~ ,~,~ ~/-%~. ~C.
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR TNDIRECTLY, A 5% OR MORE OWNERSHIP TNTEREST IN SUCH
CORPORATION, PARTNERSHTP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issuc:t~o be lobbied (Describe in detail): ~'~ ~
III. CI'[Y AGENCIES/INDMDUALS TO BE LOBBIED:
IA) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
FLAT RATE OR OTHER,):.
A) LOBBYIST DISCLOSURE: (Required)
B) PR/NCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
The following information must be answered:
DZSCLOSURE OF TERMS AND AHOUNTS OF LOBBY/ST COMPENSATZON (DZSCLOSE WHETHER HOURlY~
1)
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
Yes N No: Are you Iobbvina on a oresent or oendina bid for aoods, eauioment or services, or on a / ' present or DendinQ award for aoods, eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
~Ye~ l~No: Are you Iobbvina on a Dendina application for a Development Aareement with the City or
/ application for chanQe of zonino mad desionation or chanoe to the City's Future Land Use
MaD?
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..
~l~Yes [] No: Are you reDresentino a not-for-Drofit corporation or entity without soecial compensation
/ 9r reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYZST SHALL SUBMIT TO THE ClTY CLERK A SZGNED
STATEMENT UNDER OATH, LZS1/NG LOBBYZNG EXPENDTTURES, AS WELL AS COMPENSATTON
RECEIVED, TN THE CITY OF MT~MT BEACH FOR THE PRECEDTNG CALENDAR YEAR. A STATEMENT
SHALL BE F/LED EVEN TF THERE HAVE BEEN NO EXPENDI'TURES OR COMPENSA'rZON DUR/NG THE
REPORTING PERZOD.
! do solemnly swear that all of the foregoing facts are true and ~ct and that'-l~have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. ~-~/~
Signature of Lobbyist:
Signature of Principal/Client: /
LOBBY/ST TDENTZF[CATZON:~ PRZNC/PAL IDENT~FICATZON:
D Produced ID
Form of Identification
Personally known (Lobbyist)
[] Produced ID
Form of Identification
[~ersonally known (Principal)
VTT. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworq t_.q~d subsr, r2aed_Lbefore me ~"'~bscribed before me
This//)~/ day'of ~/]~_ ,20{~.~'~;i,~f, ROBERTA H.~DON d~y of ,20__
~/~ ~
SignOre of Pu~ Nomw - State of ~ FL ~ ~~ublic NO~W - S~te of Florida
Nobri~tion of Lobbyi~'s signature
No~rization of Principars signature
Annual Registration f~: [ ] Yes [~No ~o~~
Lobbyist R~is~afion Form received and vedfi~ by:
F:~CLER~$ALL~MA~-M~Lobbyi~LOBBYI~ ~RM'~d~