Yvonne E. McCormack/Yvonne McCormack
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 v~tell ~ any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-343ti t /11 ~ a<
NA O BBYI (ast) (irs (M.l) .-
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State (Zip Codej
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY:
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NA E OF PRINCIPAUCLIENT: ,
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BUSINESS NAM AND ADDRESS Number and Street) ( ity) (St e) (Zi Code) / ,
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TELEPHONE NUMBER: FAX NUMBER: (Optional) MAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• 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.SPECIFICL
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-482(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
~~
N, DISCLOSURE OF TERMS AND AMOUNTS OF L09BYtST COMPENSATION (DISCLOSE WHETHER ffOURtY, FLAT
RATE OR OTFIER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE {OF LOBBYIST COMPENSATION}`
{Required).
The following information must be answered:
Pursuant to Miami Beach City Code Section 2.488 Entitled "Prohibited Campaign Contributions. By Lobbyists
On Procurement issues":
^ Yes ^ No• Are you lobbying on a preaerrt or pending bid for goods. equipment orservices~_or_on a
p~g,$gn~X pending award for snoods equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues':
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- onty appears as a representative of gaol-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.
^ Yes ^ No• Are you represerttina a not for-profit corporation or entity without speciaLcomoensation or
r,,~imbun~mgr+t.
SIGNATURE UNDER OATH.:
Signature of Lobbyist `
1 do solemnly swear that ail 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 ail reporting requirements.
Signature of Lobbyist:
Signature of Principal/Clienti . Xt It 1 l
VI. LOBBYIST IDENTIFICA~ TIDE N:
^ Produced ID
form of identification
^ Personally known (Lobbyist)
Vti. Sit3NATURE AND 8TAMP OF NOTARY:
State of Florida, County of Miami-0ade
Swum to and subscribed before me
This day of .2008
Signatureof Public Notary-State of Florida
Notarization of Lobbyist's signature
Annual Registration tea:. [ ]Yes. [ J No Amount
Lobbyist Registration Font received and veriflsd by:
PRINCIPAL. il3ENTIFICATION:
~ Produced ID
Form of Identification to Z P Nib
Personalty known (Principal) ~ ~- ~ p
State of ~b, County of Mrarrrr~9ade ~ cv p
Svirom_ ansl subscribed before me ~ ,p ~ C
This day of ~r-~C .2008 ~r~ ~ ~ 4? .~
N
Signature ub' otary- State o ~ ~/~ ~ .~ C1 ~
Notarize n of nci I's signatun~ : y U
MCR
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florido 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fox: 305.673.7254
LOBBYIST NAME:
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been reso{ved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature:
f~s~vis2cJ 0?_/04i200S
i
Date:
, ~ ;~; ': ;.~ ~•. ;ins: