Kent Harrison Robbins/MDPLm MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
SPECIFIC LOBBY ISSUE:
be lobbied (Describe in detail):
Grd~cr~s
Cam Alo. H1°~3 ~ S~17
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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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 Ordin((anc~~e 2~~004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Nun~er and Street) (Cify) (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)]
• ME OF HIEF OFFICER, PARTNER, OR BENEFICIARY:
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
C~g}RPORATION, PARTAAN~~RSHIP OR T UST: L
~~
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) Q n
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ ~
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":
^ Yes i>oAVO• Are you lobbvina on a present or uendina bid for goods eauiument or services, or on a
present or uendina award for goods eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
_^Yes idl4~o• Are you lobbvina on a uendina auDlication for a Develoument Agreement with the City or
~nuli~tion for chance of zoning mau designation or chance to the Citv's Future Land Use
Ma°?
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..
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 FOR THE PRE DING CALEN RYE STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO~IfI~N ORES O~f,' ~EN ION D~fRING THE
REPORTING PERIOD. n J ~.
Signatui`e of Lobbyi
I do solemnly swear that all of he fore oing cts are tr an correct and that I have read or am
familiar with the provisi s o fined i ~0 2-482 the • Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
~ Produced ID Produced ID
Form of Identification,~,~, Form of Identification
~l Personally known s ~L~ Pe Wally known (Principal)
NOby h~bNc - MoN d fbiWo
VII. SIGNATURE AN ~''~
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State of Florida, County of ~~~ Florida, County of Miami-Dade
Sworn to d subscribed o e worn and subscribed before me
Th y of _ , 20~ ~ This day of , 20_
r
Signature of Pub i otary - State o lorida Signature of Public Notary -State of Florida
Notarization of Lobbyists signature Notarization of Principal's signature
FOR CLE K'S U ONLY
Annual Registration fee ]Yes [ ] No Amount Paid MCR # - ~ - Date Paid
Lobbyist Registration Form received and verified by: >
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04