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Beth Sobol . . lD ~ MIAMIB 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 dty 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 specifie exclusions. Please refer to Ordinance 2004-3435. ~~ ~CJl~\ NAME OF LOBBYIST: ' <\ 5'-\ - '-\ ~-5 % I TELEPHONE NUMBER: I. LOBBYIST RETAINED BY: ~~\.o~ \ ~~ 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 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 ISS \J III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship D~\\~ . ,> IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y, FLATRATEOR OTHER): {) A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required), o 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": D Yes ~: Are you 10bbvinG on a Dresent or DendinG bid for Goods. eGuiDment or services. or on a Dresent or DendinG award for Goods. eauiDment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": DYes DJ{c): Are yOU 10bbvinG on a DendinG aDDlication for a DeveloDment AGreement with the City or aDDlication for chanGe of zoninG maD desiGnation or chanGe 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.. ~ D No: Are you reDresentinG a not-for-Drofit corDoration 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, USTING 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 ~ D OOE ITEOTlON DURING THE REPORTING PERIOD. , 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 provl~on lalned in ~n -482 he Miami Beach Gty Code and all reporting requirements. ? _ ~ Signature of Lobbyist: Signature of Principal/Client: VI. o Personally known (Lobbyist) VII. Signature of Publ c Notary - State of FI rida Notarization of Lobbyist's signature Date Paid \ cf (p { (J!) Revised 12/08/04