Shari R. Wald/Roney Palace Condo~J, + ~?~ .. ~.. fit, ~``s_/ ~.,.,.., ,
'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 do Ordinance 2004-3435. ~~ ~ ~ ^I - _
NAME OF LOBBYIST:
i~RE,,~S•j ~~umber
(First)
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(M.I)
Sma-t~~.co-v~
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Flll out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~~ ~ M'~ ~ (,.f/V• -~~ d~~1
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FAX NUMBER:
LOBBYIST RETAINED BY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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II.SPECIFIC LOBBY ISSUE: 1'~' ~"~~
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Issue to be lobbied (Describe in detail): (~O ~~ ~~ i _ A, ll
lll. CITY AGENCIES/INDIVIDUALS TO BE LOB (Pursuant t/ City Code section 2-as2(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) An Financial, Familial or Professional Relationship
a
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RATE OR OTHER):
A) LOBBY-ST DISCLOSURE: (Required}
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPE
(Required).
The following information must be answered:
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1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
3) Pursuant to JVliami -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 o(ipositoh' to ahy item, shall register with the clerk as required by this
sect n but, shall not be required to pay any registration fees.
Yes No: ArP vnu rnn~e~enti.. ......a s__ __t.~_-
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, ion 2-482 the Miami Beach City Code and all reporting fiequirements.
Signature of Lobbyist:
Signature of Principal/Client:
Vl. LOBBYIST IDENTIFICATIO PRINCIPAL IDENTIFICATION:
uyrroduced ID d ID ~~'LO
Form of Ide i -on Form of Identification ~ e
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^ Personally known (Lobbyist) ~ ~
x
^ Personally known (Principal) ~
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VII. SIGNATURE AND STAMP ; ~ ~
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State of Florida, County of Miami-Dad
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Sworn to and subscribed efor State of Florida, County of Miami-Dade W
~
e me
This ~i'~ 2 $~ ~'~~
day 0 ~; Sworn an subscribed of re me
Thi ~~~
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. 2008
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Sig ture o u of
Notarization of Lobbyist's signature Si nature Nota State of FI "'
Notarization of Princpa gnature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid S ~"'
Lobbyist Registration Form received and verified by: MC
Date Paid
F:\CLER\HATL\Form~ i:obby;-t k-5,..,:-:-,..,r: c~.-n;.rc•<
Revised 03/ 7/2008
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resent or oendina award for adods eauioment or service
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2) Pursuaht to Miami Beach City Code 21490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
- - --- - - •...~~ ~ G~.IAI {iVl-1 ensanon or
reimbursement. .
V. SIGNATURE UNDER OATH:
~~` ~ ~~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachEl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
CityClerk@miamibeachfl.gov
i b~afd
I understand that no later than October 1st of each xear, 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 resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: Date:
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