Lee B. Schrager/So. Wine & Spirits of So. Fla~? 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 ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EM L:
I. LOBBYIST RETAINED 8Y:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NU BER: FAX NUMBER: (Optional) EMAIL: (Optional)
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 Indiv
i
dual/Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLATR.4TEOROTHfR):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
The following information must be answered:
Produced ID
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
~1(es ^ No• Are you lobbying on a present or pendina bid for aoods equipment or services or on a
present or pendina award for aoods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes ~NO' Are you lobbvina on a pendina application for a Development Agreement with the City or
application for change of zoning man designation or change to the City's Future Land Use
Mao?
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..
B~Yes ^ No• Are you representing snot-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 FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE NAVE BEEN NO EXPENDI RES OR COMPENSATION DURING THE
REPORTING PERIOD.
Si ture of Lobbyist
I do solemnly swear that all the foregoing facts are true a rrect and that I have read or am
familiar with the provisions ained in Section 2-482 of the M mi Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: .~~PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed efore me
Tf~is~~day of ~r~20 U`7 /-'
~Knature of Public Notar~5'f~ate of Flor
N arization of Lobbyist's signature
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Form of Identification
known (Principal)
of Florida, County of Miami-Dade
~ and subscri e ~.be,,f~o~re~,me
~ay of ~~~~~ 200
tiignati~ofi Public Notary s Stage bt: Florida
Notarization of Principal's signature
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FOR CLE K'S U ~ LY ,n,
Annual Registration fee~']~~ j Yes ( ] No Amoun ~ ~ i MCR}x ~""~k-"' Date Paid LJ'j
Lobbyist Registration Form received and verified by: ~ ~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc '~~ Revised 12/08/04