Agnes Youngblood/Community Center Associationm 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.
NAME OF LOBBYIST: (Last) (First) Z '3 j ~ ~~ /fir ~_ (M.I)~ !/f--
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BUSINESS NAME AivD ADDRESS (Number and Street) (City) (State) ~ ~~ (Zip Code)
NUMBER: FAX NUMBERi1 ~I ® EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF
'I'ti'~ / 7
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
TELEPHONE NUMBER: FAX NUMBER: (Opp; nal) 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:
to be lobbied (~scritte in
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 AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERJ:
A) LOBBYIST DISCLOSURE: (Required) n'Z`~ ~ '~~°~U'`~''^~ ,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). /i%+-~' ~~~'~i ''G~""
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 ^ Noa.aCre you lobbying on a present or pending bid for goods, equipment 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":
^Yes ^ Nox! Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (excep*. 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..
i9'~es ^ 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 FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
c-~`~ ~~, .__ _ _~
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Si~n~fture 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 reporting
requirements. ,-.,_,
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn o nd subscrib b for me ,, ,
PRINCIPAL
C Produced ID
Form of Identification
~; Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 20_
GRAZIEl1A L 0
Signature o .Public Notary - Sta ~ ~~ ~"': re f Public Notary -State of Florida
:,= MY COMMISSION # ~3i
Notarizat;on of Lobbyist s si ` itP .: r~z on of Principal's signature
~•.. ;; EXPIRES: July 10,
~'^"~`~ bonded Thru Notary Public Underwrfters
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