Christopher Middleton/Goldwater
Mami Ikl;xh
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA nON 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 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 specifically includes the
principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exdusions, Please refer
to Ordinance 2004-3435.
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BUSINESS NAME AND ADDRESS
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(Number and Street) (City) (State) (Zip Code~
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EMAIL:
(Last)
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NAME OF LOBBYIST:
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TELEPHONE NUMBER:
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FAX NUMBER:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CUENT:
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BUSINESS NAME AND ADDRESS
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(Number and Street) (City) \ (State) \
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FAX NUMBER: (Optional)
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(Zip Code)
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TELEPHONE NUMBER:
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:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe In detail):
III, CITY AGENCIES/INDIVIDUAlS TO BE LOBBIED:
A) Full Name of Individual/ntie
B) Any Financial, Familial or Professional Relationship
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IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAnON (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 0 - fl..a\"( ii\,.~
Ye$~ ..::.=. reDresentlna a not-for-Drof"lt cornoration or entitY without soedal comnensat:ion or
. u pursuant to Ordinance No. 2004-3435.
1)
~~: ~:e~Ii~=:~. ~:~-3=~~~in~ ':;~~ atv Code Chapter 2. Artk:k! VI~ ~~=n 5
_. E'" . Fe" T i' Code Section 2-488 Entitled "Prohibited
Q;m;ic;n Q;ntributions BY Lobbvists On Procurement Issues";
Are ~ Iobbvina on a nresent or. nendina bid for aoods. eauioment or services. or on a Dresent
or ~i;;;a~for ~.iimem or semce?
pu:r :~i~=:. ::-:5 ~endina M:i ~ g: Code Chaoter 2. Artk:k! vn Division 5
th~;;~ ~_ "bt' i n Fi__~__rm"_ Via TheA_iti_n __eSection 2-490 Entitled "Prohibited
Cam_ion _om_ions Bv Lobbvists On Real Estate Develooment Issues";
Yes @ ::~:~~':.a~ae~~~n:o~:~:,:;:::==ex==~~u~ MaD?
Yes (5
2)
V, SIGNATURE UNDER OATH:
ON OCTOBER 1ST Of EAOI YEAR, EACH LOBBYIST SHALL SUBMIT TO THE arv CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE arv OF MIAMI BEAOI FOR THE CEDING CALENDAR A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO E RES OR N DURING THE
REPORTING PERIOD.
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 ined in Section -4 Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFlCAnON: PRINCIPAL IDENTIFlCAnON:
~ced 10 ,AfJp -1/7-69 ,ybl-C7 0 Produced 10
1<- p ~ L- Form of IdentifICation Form of Identification
o Per.;onal~ known (Lobbytst) ~I~ known (Principal) =:>
YD. SIGNATURE AND STAMP OF NOTARY: -
State of Florida, County of Miami-Dade
Swom alJ5i,subscribed ore me
This .LS.....day of
Sig re of Publk: Notary - State of Florida
N~ri ~si Nrture
7..""",
FOR CLE~~SE ONLY
Amual Registration fee: ~ Yes [ ] No Amount Paid I 9C) MCR # :2-=t~ ~i>ate Paid
Lobbyist R.egistration Form received and verified bY~ ~ ~
Revised 02/10/04 : R\ALL\MARIA-M\LOBBYIST\LOBBYIST FORM 04