Patrick Ilabaca/James Ganleym 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; (Last) (First) (M.I)
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BUSINESS NAME AND ADDR SS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT,
BUSINESS NAME AND ADDRES (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: 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 BENEFICIARY;
• 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);
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AHD AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE; (Required} P~ i'~T 01~ ,~Iq-C.J~-I2'~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION); (Required). ~i4-~2-T A~ ~l~ L4 (Z `>'
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":
o'Yes D No: Are ou lobb in on a resent or endin bid for oods a ui ment or services or on a
present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
oyes ~Vo: Are you lobbyina on a pending application for a Development Agreement with the City or
application for chanae of zoning map designation or chanae 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 anot-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„
~ Yes [~'No: Are you representing anot-for-profit corporation or entity without special compensation
or reimbursement. ,
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ 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 FORT R EDING CALENDAR YEAR. A STATEMENT
ALL BE FILED EVEN IF THERE HAVE BEEN EXPEN TURES 0 COMPENSATION DURING THE
PORTING PERIOD,
~~
'~ ~ ~ ignature of Lobbyist
w ~ o solemnly swear that all of the foregoing facts are true and correct and that I have read or am
'" ~ ~ ~ iliar with the provisio con in d in Se ion 2-482 of the Miami Beach City Code and all reporting
~ ~,
~ ~ . ~ ~ quirements.
nature of Lobbyist;
~~,
,,~;~t~ '~~,, nature of Principal/Client:
~~
~= LOBBYIST IDENTIFIC N:
P CIPAL IDENTIFICATION.
~~+~'"'~~"¢' ~ ~ Produced ID ~ Produced ID
Form of Identification Form of Identification ~
~_ Personally known (Lobbyist) a Personally known (Principal)
1~'IT-~ SIGNATURE AND STAMP OF NOTARY: '
~ ~ ~ State_~f Florida, County of Miami-Dade State of Florida, County of iami-Dade
', ~ S~~vr~ t~} d su crib for Sworn a subscri d befo me
This 1 ~ d of 2
y 0_ This day 20_
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Signature of Pu lic N tary S of Florida Signature of Public Nota - Sta a of oriel
Notarization of Lo byist's signature Notarization of Princip I's si nature
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FOR CLER ' USE ONLY _ -~
Annual Registration fee; [ ]Yes [ ] No Amount Pa' ~. MCR # ~~ Date Paid .~ ,~ G~
Lobbyist Registration Form received and verified by; ~w
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05,doc Revised 12/08/04