Beth Sobol/City Style
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MIAMI BEACH
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 refer to Ordinance 2004-3435.
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(Number and Street) (City)
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I. LOBBYI~AINE. 0 BY:
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NAME OF PRIN L/CUE' -
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BUSINESS NAME AND ADDRESS
(Number and Street) ,
(City)
(State)
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (e)l
. NAME OF CHIEF OFACER, PARTNER, OR BENEACIARY:
. 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 10' d (Descri in detail):"',~v ";",' ,:,'t' ~,
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III. CITY AGENCIES/INDIVIDUALS T,L088IED:' ,
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inancial, Familial or Professional Relationship
A) Full Name of Individual/Title
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). \\':) t\., ~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
o Yes ~: Are YOU lobbyinG on a Dresent or DendinG bid for Goods. eGuiDment or services. or on a
Dresent or DendinG award for Goods. eGuiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes~: Al]l VDl!lDbl1vinll Qn a pendinG ilPD'i....tiDI] for i! Devl;lIQDm!:nt A!lreem~nt ~~ ~h~~~ ~r
aDDlication for chanae of zoninG maD desiGnation or chanGe to th~ Ci_ls F ___r _ __ \Le
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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 on-Iy 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..
DYes &0: Are you reDresentinG a not-for-Drofit corooration or entity without sDecial comDensation
or reimbursement. .
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 EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALEND R YE . A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EX., DIT RES CO P NS N DURING THE
REPORTING PERIOD.
VII.
I do solemnly swear that all of the fore oing facts are true and correct and that I have read or am
familiar with the prg)lisiolfseon ined in e ion ~82 e Miami Beach City Code and all reporting
requirements. < ~ ' i
Signature of Lobbyist:
Signature of Principal/CUe t:
VI. LOBBYIST IDENTIFICATION:
~~dUCed ID
10
Form of Identification
Form of Identification
o Personally known (Lobbyist)
nally known (Principal)
State of Florida, County of Miami-Dade
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Si nature of Public Notary State of Florida
Notarization of Lobbyist's signature
Signature of Public Notary - State of Florida
Notarization of Principal's signature
FOR CL~K'S USE ONLY I
Annual Registration fee: [V1"Yes [ ] No Amount Pa~ , e5() . MCR # ~ ~ Date Paid II! -=t !~~
Lobbyist Registration Form received and verified by: ~ ~
F:\CLER\$ALL\MARIA-M\Lobbyist\LO YIST fORM OS:-tMc Revised 12/08/04