Andrew James/M. SamuelMIAMiBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persof~s employed or retained, whetJ~er 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, derision or recommendation of any city personnel during the time
period of the enUre decision-making pro~es~ on such action, decision or recommendation that foreseeably wilt be heard or reviewed
by the Oty commission, or a city board or committee. The term spedfically includes the p~i.'ncipal as well as any employee eng~ed
/n lobbying activities. The term "Lobbyists~ has specific exclusions, Please refer to Ordinance 2004-3435.
IE 9F _L.O~ B I.S~l'_: ...... I~,$) / "' (Fir~) (M.I>
BUSINE~ N~ ~D ~D~SS - (N~ and Street) (Ci~) (S~[e) {~p C~e)
~ELEPHO~E NUMBER: F~ NUMAR: E~L:
I. LOBBYIST RETA][NED BY:
l~ltcl, l&el.,
NAME OF PRINCIPAL/CLIENT:
BUSINF$S NAME A~iD ADDRESS
TELEPHONE ~UMBER:
(State) (2ip Code)
EMAIL: (Optional)
Fill out this secUon 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: .
SPECIFIC LOBBY ~SSUE:
Issue to be lobbied (Desoibe in def~ail):
m. CTTY AGENCZE$/INDIVIDUALS TO BE LOBBZED:
A) Full Name of lndividual/TiUe
B) Any Financial, Familial or Professional Relationship
A) l_OBBYt~ Dt~L.OsuRE: (required)
The following information must be answered:
Pursuant to Miami Beach City Code Section 2-48~ Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
13 Yes XNo: Are you IobbvinQ on a present or perldillq bid for aoods, eauiornent or services, or on a
present or oendina award for uoods, euuiDment or service?
Pursuant to Miami Beach CiW Code 2-490 Entitled "Prohibited Campaign. Contributions By Lobbyists On Real
Estate Development Issues":
BYes .~&~No: Are you Iobbyinq on a Dendinq aDDliCaUon for a Development AQreement with the City or
a~lication for chan..cje of zoninq map desiqnation or chan,cje t;q the City's Future Land Use
3)
Pursuant Lo 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..
[] Yes ~ No: Are you reDresentinQ a not-for-profit corm)ration or entity without special compensaUon
. -
or reimbursement. ·
V. STGNATURE UNDER OATH:
ON OCTOBER Isr OF EACH YEAR, EACH LOBBYIST SHALL SUBMTT TO THE CTTY CLERK A SZGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSAT:[ON
RECEIVED, IN THE CITY OF M]AM! BEACH FOR THE PRECED:[NG CALENDAR YEAR. A STATEMENT
SHALL BE F]LED EVEN IF THERE HAVE BEEN NO EXPEND]T~U~ ~ C~~N DUR/NG THE
REPORTING PER/OD.
"~natU~; of LtbyJst
! do solemnly swear t. hat all of the foregoir facts are true and cor'rect~nd that ! have read or am
n 2-482 o~iami Beach City Code and all reporting
familiar with the provisions contained i~
requirements. /I. II
Signature of Lobbyist: / /I Ii / /'/~"?. )~".~-, ' ~ ....
Signature of Principal/Client:
VI. LOBBYIST ZDENTIF~CATIO__N :.~ ,,I ,'%1 / PRTNCIPAL ZDENTIFICATION:
Form of ldentificaL~on Form of Identification
Personally known (Lobbyist) '~:~er~lly known (Principal)
viz. SZONATURE AND STAM OF OTARY:
-
State of Florida, County of Mlami-Dade' ' StaLe of Florida, County of Miami-Dade
/
SwotR to .and subscribed before rn_e ,,.--- Sworn.~niL~subscribecl before rne
Th~s ~%~ day or.l'~r~41.~, 20__03 .-~ ~s ~day of /)X~X' , 20_~ .~
~/'Sig~ture of Public Notary - State of Florida ~ Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature ~'~'
lX~] ~e~ FOr CLEI~,,~.~USE ONLY ,2 ~(~;2-,I
Annual Registration fee: [ ] No Amount Paid J_~ MCR Date Paid ~.b~
Lobbyist Registratio~ Fom~ received and verif'~::l by:
F:\CLER~$ALL\IVlARLA-M\LolYoyist\LOBBYTST fORM OS.doc Revised ~2/08/04