Hiram A. Ruiz/Rob Schuler - Fisher Island Bldg permit~~~~ ~~
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FE. 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, deasion or recommendation of any city personnel during the time period
of the entire decision-making process on such action, deasion or recommendation that foreseeably will be heard or reviewed by the
city commission, or a city board or committee. The term speafically includes the principal as well as any employee engaged in
lobbying activities. The teen "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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LEPHONE NUMBER:
(Last) (First)
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(Number and Street) (City)
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1. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
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(Zip Code)
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EMAIL:
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(Number and Street) (City) (State) (Zip Code)
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FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (cq
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE'. OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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Issue to be lobbied (Describe in detail):
ul. CITY AGENC#t`S/INpIydDU~1J.:.S Tp B~ LC~BBIEA:
A) FuU Name of IndividuaUTitle B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER NOURLY,
FLAT RATE OR OTNER).
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Nl ~
A) LOBBYIST DISCLOSURE: (Required) d
The following information must be answered:
1) Pursuant to Miami Beach City Code Sedton 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On~Procurement Issues":
o Yes l~No Are you lobbvina on a Dresent or Dendina bid for goods eauiDbtent or services or on a
oresent or uendina award for goods eouioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes Glwo Are you lobbvina on a pending aDDlication for a Develoument ~4areement with the City or
~~~lic..~ion for chance of zoning map designation or chance to the C~tv's Future Land Use
Mau?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Sed:ion 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 derk as required by this
section but, shall not be required to pay any registration fees..
o• Are re ~n - r r e wi n 'on
• or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO T"HE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS 1NELL 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. ! ~ -
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 reporting
requirements. ~ A ,,~
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Signature of Principal/Client: .~- - -
Signature of Lobbyist:
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 dfici s<abscri fore
This ~_day of
ig P lic otary -State of Florida
N anon of Lobbyists signature
i Produced ID
Form of Identification ° ~ ~
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State of Florida, County of Miami-Dade m ` `~ ~
Swom a ?d subscribed befc}reme
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Signature o~Public Notary -State of Florida
Notarization of Principal's signature
1 FOR CLERK'S USE ONLY ~ ~o `'
Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # ~Q ~ ~Da Paid
Lobbyist Registration Form received and verified by: ~ I I S~n~ /
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12 08/04