Bill Farkas/MDPL 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.
NAME OF LOBBYIST: (Last)
BUSINESS NAME/~NDADDRESS (Number and Street)
(First)
(City)
TELEPHONE NUMBER: ' FAX NUMBER:
(M.I)
,aa. ~'
(State) ~ (Zip CAe)
EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRiNCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
(Number and Street) (City)
FAX NUMBER: (Optional)
(State)
Code)
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:
Issue to be lobbied (Describe in detail):
III. CD'Y AGENCTES/IND1%/~DUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSA'rZON (DISCLOSE WHETHER HOURLY~
Fz~ r ~4 r~ oR
A) LOBBYIST DISCLOSURE: (Required) ~ '>/~ L~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
[] Yes~/~o: Are you Iobbyinq on a present or pending bid for goods, equipment or services, or on a
present or pendin.q award for .qoods, equipment or service?
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Ni~es [] No: Are you Iobbyinq on a pendin,q application for a Development Aqreement with the City or
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..
/~es No: Are not-for-profit corporation or entity without special compensation
you
representin,q
a
or reimbursement..
application for chanqe of zoninq map desiqnation or chanqe to the City's Future Land Use
V. SIGNATURE UNDER OATH:
ON OCTOBER Isr 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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURZNI3 THE
Signature of Lobbyist
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 contained in Section 2-482 of the Miami .Beach~ Code and all reporting
requirements. Z/~/ /]~' - ~-'~~~//
Signature of Lobbyist: ,
Signature of Principal/Client:
/pOBBYZST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
roduced ID Fb C ~- ~: ~2. q ¢O:5133¥O [] Produced ID
Form of Identification Form of Identification
[] Personally known (Lobbyist) ; [] Personally known (Principal)
/ OFFICIAL NOTARYSEAU
VII. SIGNATURE AND STAMP OF NOTARIY' LILLIAN BEAUCHAMP
' i NOTARY PUBLIC STATE OF FLORIDA
IM Cc~O~MM~.~~(~'-~'8~° u nt r of M ia m i- Dad e
State of Florida, County of Miami-Dade y
Sworn to ao~l subscribe~l.before me ~~ )efore me
This Iq ~4~ day of /L{ 0t'clq , 20__~_o(o This day of ,20__
S~gnature of Public Notary - State of Florid~ Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
I~ Ir~ I~ ~ L3t',4~i'T" , FOR CLERK'S USECU~L4'
Lobbyist Registration Form received and verified by: .~~ -
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.~t~;J~-'-" ~ Revised 12/08/04