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Dona Zemo/Miami Beach Chamber of Commercem 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. ~ C~~ -~~ ~ ~~. NAME OF LOBBYIST; (Last) (First) ~~ ~ , ~ ~ BUSINESS NAME AND ADDRESS °~~. ~ - _~ I ~ ,~ TELEPHONE NUMBER; (Number and Street) (City) I ~~ ~ ~~ ~ ;~ 1 FAX NUMBER: (M.I) a ~ ~ ~ ~~ ~.~ (State) (Zip Code) E ~ ~ ~ ~~ , EMAIL; I. LOBBYIST RETAINED BY: s E t ~ _ .-+ ,. -- NAME OF PRINCIPALJCLIENT: i ^G~ C`~~~C.~--- ,,~ ~,, BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code) 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: r ~' Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: ~~~~,~ A}~f~-Name of Individual/TiNe B) Any Financial, Familial or Professional Relationship ,~~ ~. ~~ N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER ~a ~~~~' A) LOBBYIST DISCLOSURE. (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION : R ~ ~ (equired). 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": Y ~ o; Are ou lobb in ona resent or endin bid for oods a ui ment or services r ,o ona present or pending award for goods, eguiament or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes ~ ~ :Are ou lobb in ona endin a lication for a Develo ment A reement with the Ci or a lication for chan a of zonin ma desi nation or chan a to the Ci '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 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.. 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 FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPEi~D~TURES OR COMPENSATION 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 provisions contained in Section 2-482 of the Miami Beach City Code and all reportin 9 requirements. . ___. , ~ :, ~~ Signature of Lobbyist: - ~ ~ `~ ~ ~l~ Signature of Principal/Client, VI. LOBBYIST IDENTIFICATION; PRINCIPAL IDENTIFICATION: ~ Produced ID Form of Identification b' Personal) y known (Lobbyist) D Produced ID Form of Identification Personally known (Princi al P) VII. SIGNATURE AND STA ,,,,~~r p~~,,,"" ~' I.1111AN BEAUCHAMP 416 ULLIAN BEAUCHAMP '',',Y ~~ ~~,,,~ *;` ~ MY COMMISSION # DD 530416 '~~~~~ ~"'• MY COMMISSION # DD 534 State of Florida, County of Miami-D a ~~ EXPIREg; April 29,~@e Hof rida, County of '~; o ,; ` EXPIRES: April 29, 2010 Sworn to and su {, :~~, . ~.• P~ ~ t.~, m~N~ P~~unae bscnb before e, ,~r ,; ,~~~,, e«~am~,No~-~y subscn d befog . ' ry ~erB This ~_day of is da y of , 20_ . Signature of Public Notary -State of lorida Signature f Public No ry -State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature FOR CLE 'S ONLY ' Annual R istration fee: ~ `~~ eg [ ]Yes [ ] No Amoun P ' r ~ MCR ate Paid Lobbyist Registration Form received and verified by: F:~CLER~$ALL~MARIA-M~Lobbyist~LOBBYIST fORM 05.doc Revised 12/08J04 V. SIGNATURE UNDER OATH: