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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 defined in any
manner in this section, 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:
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BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
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(City)
-51)0
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(State)
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(Zip Code)
(Last)
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(Number and Street)
(First)
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CUENT: t
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BUSINESS NAME AND DDRESS
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TELEPHON NUMBER:
Y 75
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(City)
Vi'/!' (vL;V1'",v ~ Otk
(State)
(Number ana Street)
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFIOARY:
· 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 lobbied (Describe in detail):
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any FinaQs;ijll,i~miliaJ._,Professtorfal 'A.elalion$hip
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (ReqUired)iJ ;;~ L n: / h i.V
,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 11;; '{""C. c ". / l)(hV'
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o Yes ~o: Are vou reoresentinCl a not-for-orofit corooration or entity without special com6ensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 AmendinG Miami Beach City Code Chapter 2, Article VII, Division 5
Thereof Entitled "CampaiGn Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
CampaiGn Contributions By Lobbyists On Procurement Issues";
D Yes ~:
2)
Pursuant to Ordinance No. 2003-3395 AmendinG Miami Beach City Code Chapter 2, Article VII Division 5
thereof Entitled "CampaiGn Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
CampaiGn Contributions By Lobbyists On Real Estate Development Issues":
DYes ~o:
Are YOU lobbvinQ on a oendinQ apolication for a Deveiopment Aareement with the City or
application for chanCle of zoninCl map desiClnation or chanoe to the City's Future Land Use Map?
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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN ~t1EXPENDITU S OR PENSATION DURING THE
REPORTING PERIOD. \ \
"
I do solemnly swear that all of the foregoing f . ts ar(}'true and correct and that I have read or am
familiar with the provisions contained . ion 2- of the Miami Beach City Code and all reporting
requirements. (
Signature of Lobbyist:
- ?::CI~AL IDENTIFICATION,
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VI. LOBBYIST IDENTIFICATION:
o Produced 10
D Produced 10
Form of Identification
~rsona"y known (Lobbyist)
Form of Identification
~sona"y known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to pnd subscribed before me ...,
This d- ;;l\), day of GI\/\ lrU/1 . 20(2..1
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"'m"~flo.RY P(J~;'~.. )\,
f~.. .. "''': Notary PUblic - State ot Florida
~:~. · :EMy Commission Expires Apr 18. 2009
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""""., Bonded By National Notary Assn.
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Annual Registration fee: [ ] Yes [ ] No Amo
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F:
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cJ MCR # ~Date Paid 2q Or
LL\MARIA-M\LOBBYIST\LOBBYIST FORM 04