Perry Adair/Joel Simmonds/MB Management L.C.
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MIAMIBEACH
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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NAME OF LOBBYIST: . (~~ (First) (M.!)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
PAO,6-ilt.@, ~-~~"RoW. (J)M
EMAIL:
60s J 'U,Q']..... +4~.3
TELEPHONE NUMBER:
(30& ') -+4 2..... 2:1...32-
FAX NUMBER:
I. LOBBYIST RETAINED BY:
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ME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
F L.o~t){.\.
(State)
33~
(Zip Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c))
NA~OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
J cx../ S i,.,. "." 0 n d j
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 ~~ri~ in detail): ~
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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Not-te,
IV. DISCLOSI:JRE OF TERMS AND AMOUNTS OF lOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RA TE OR 077lER): it
A) LOBBYIST DISCLOSURE: (Required) .HOUR.l~ tk 315. ~ I nou{.L
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). t '3'1-5. ~ I ~o(2..
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":
OYes'lNO: Are YOU lobbyina on a oresent or oendina bid for aoods. eauioment or services. or on a
oresent or oendina award for aoods. eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
~Yes 0 No: Are YOU lobbyina on a oendina aoolication for a DeyelODment Aareement with the City or
aDDlication for chanae of zonina mao desianation or chanae to the City's Future Land Use
Mao?
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..
DYes riNO: Are YOU reoresentina a not-for-orofit corDOration or entity without soecial comoensation
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,P EDING LENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPEN TUR OR COMPENSATION DURING THE
REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the forego' g facts are true and correct and that I have read or am
familiar with the provisions contain i,n ction 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI.
lOBBYIST IDENTIFICATION:
PRINOPAL IDENTIFICATION:
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Form of Identification
" Personally known (Lobbyist)
Form of Identification
~SOnallY known (Principal)
VII.
SIGNATURE AND STAMP
State of Florida, County of Miami-Dad ~~~ GLEXANDRIA 1>6t<<\li\ ~RIer~ ,County of Miami-Dade
Sworn to and subscriQedbefore!TI) '" ..~ MYCOMM/SSJQf.tJ~~Ju scribed before me
This 1'3 day of NO I!a{)~ 2 1 GFfI..... EXPIRES: iftlli~~da of ~o.l'l""",,~~r. 20D,,0
~~m7)~398-0153 FIoridaNofalyS8fVfce.com . "
Sig ure 0 Public Notary - te of FlOrida Signature of Public 'NQt '- State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
-/ FOR CLERK'S USE ONLY . c:
Annual Registration fee: [vJYes[ ]No AmountPaid ..25.ClU MCR#.:2.31-' ('\4, DatePaid \l/:l'C'fO(o
Lobbyist Registration Form received and verified by: ~o...~~'"
F: \CLER\$ALL \MARIA-M\Lobbyist\LOBBYIST fORM Os.doc Revised 12/08/04
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