Dana Keith/Miami Beach Film Society
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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
., IOOby"9 ,,""'"~. The te~ "loKE nit"' ~dU~OM. Ple...;V" to Onli...", 200+3435.
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) Zip Code) 331/ ~
3fJJ~ 673 f~6T- 3pFf3~S-I'P,h IfIIFod /
TELEPHONE NUMBER: FAX NUMBER: EMAIL: ~ (?(IV~M~ .,(fb""1
NAME OF LOBBYIST: (Last) (First)
Mf,1(J{( .6acH FILM. SO~/S
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I. LOBBYIST RETAINED ;2:-/7: 2:> r/ (V ~
NAME OF PRINCIPAL/CLIENT:
M I hM( t3Blt:,If FILM Sbtl/E/
sA-MF A-S ~LJO l/ f)
(State) (Zip Code)
BUSINESS NAME AND ADDRESS (Number and Street) (City)
TELEPHONE N@:/}II1E 45' ~U~"M")
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:
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IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
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CITY AGENCIES/INDMDUALS TO BE LOBBIED:
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A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLATRATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (ReqUired)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). A/t1 YF
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":
~es D No: Are you 10bbvinQ on a present or pendinQ bid for Qoods. equipment or services. or on a
present or pendinQ 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":
DYes %'No: Are YOU 10bbyinQ on a pendinQ application for a Development AQreement with the City or
application for chanQe of zoninQ map desiQnation or chanQe to the City's Future Land Use
Map?
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-far-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 D No: Are YOU representinQ a not-for-profit corporation or entity without special compensation
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 CALEN R YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPE E 0 PE SATION DURING THE
REPORTING PERIOD.
Signature of Lobbyist
Signature of Principal/Client:
re true and correct and that I have read or am
Miami Beach City Code and all reporting
VI. LOBBYIST IDENTIFICATION:
\d Produced lO
/' Form of Identification
~erSOnallY known (Lobbyist)
PRINCIPAL IDENTIFICATION:
'!J-P~oduced lO-n DlAi IUQ(o-/1/- tc1-0~rf-o
Form of Identification
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~ersonally known (Principal)
FOR CLERK'S
Annual Registration fee: [ ] Yes [ ] No Amount Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc
Date Paid
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VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me --t.
This /IP' day of , 20~
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Signature of Public Nota - State of Florida
Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This ~day of f~VlaUl.11' 2o..Q..1
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Signature of Public Notary - Stat of Florida
Notarization of Principal's signature
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Revised 12/08/04