Marjorie Hahn/South Fla Youth Symphonym 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 modifiption of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
City Manager or any dty board or committee; or any action, derision 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 rity commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged
in lobbying activities. The teen "Lobbyists" h specific exclusions. Please refer to Ordinance 2004-3435.
~~AN~ M~~J~~~~ ~
NAME OF LOBBYIST: (Last) (Frst) (M.I)
~~W- ~ A ~~`~- ~r n~o r ztP ~ S s w ~ 1 ~ Q.u~- ~ur~-~
BUSINESS NAME AND ADDRESS Number a d Street) (City) (State) (Zip Code)
~~ S 23~'~72~-~' was ~-sa-~ ~f~7C~ ma ~ ~ i ~a~, h @dellso-z
TELEPHONE NUMBER: FAX NUMBER: AIL:
I. LOBBYIST RETAINED BY:
~ ~ ~ ~~~
NAME OF PRINCIPAL/CLIENT:
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 BENEFICL4RY:
~a"1v(ctc~ l-~e"fe ~~' R~ "Yes j clE~~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PA ~TNE)LSrH 1PCR TRUST:
33 ~ ~1`
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II. SPECIFIC LOBBY ISSUE:
(-s- ~rrwr~- -Fig. ~~~.:~~cc..Q `~res ~~ >~ o ~ ~-~( ~ e. ~ ~ ~a~
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Titte B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLATRATEOR OTHERx /'~
A) LOBBYIST DISCLOSURE: (Required) `~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). CJ
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 1~No: Are you lobbvina on a present or pending bid for goods, equipment or services, or on a
present or cending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2x490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
OYes ~ No: Are you lobbvina on a cendina application for a Development Agreeme~rt with the City or
application for chance of zoning map designation or chance to the Citv's Future Land Use
Mau?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"IobbyisY' as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit
corporation or entity without special wmpensation 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 er>tfir without special wmcensation
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. L~%%~
S' ture o o ist
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/C
VI. LOBBYIST IDENTIFICATION:
o Produced ID
Form of Identification
~rsonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
PRfNCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
~nally known (Principal)
State of Florida, County of Miami-Dade State of Florida, County CARLC-S CENTENO
Swom to an subscribed before me Swom and subscribed cry Public - State of Fbrlda
This ~~~ay of 6~~1/ , 20Q g This 'Z~3 day of~N ~~ESapg,Zppg
~?, ` Commissbn # DD 353063
_/ ~ ~ ~ ~~ ~`` I Not~yAasn.
Si o . bli o ry -State of Flonda Signature of Public Nota
Notarization of Lobbyist's signature Notarization of Princ' signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid ~ MCR # '~'~~' Date Paid
Lobbyist Registration Form received and verified by:
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