Jeanie Hernandez/Global Spectrum/Comcast
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.
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OF LOBBYIST: (Last) "(First)
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BUSINESS NAME AND ADDRE55 (Number and Street) (C:ity) (state)
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FAX NUMBER:
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(Zip bode) ~ / ~O /
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NAME OF PRINCIPAUCLIENT: ' ~
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BUSINESS NAME AND AD RESS ( tuber and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
gut this section if principal is a Corporation, Partnership or Trust [Section 2-482
• 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:
u. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in
nl. 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 OTHER): ~~ (~q
A) LOBBYIST DISCLOSURE: (Required) ~/ ~ ~ nl ~c~.q
B) PRINCIPAL'S DISCLOSURE (OF LOBBY COMPENSATION Q 1~~~~ R~ _ _ `nom
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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":
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 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.
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT 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.
gnature of Lobbyist
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I do solemnly swear that all of the foregoing facts are true and correct and that I have r d or am fami' r wi the
provisions contained irFS~tion 2-482 of the Miami Beach City Code an~1'~I reporting r irements.
Signature of Lobbyist:
nature of Principal/Client:
LOBBYIST
Produced ID $~ ~~ ~~ , J T 3 ~ 7~S~v ~ Produced ID
Form of Identification
^ Personally known (Lobbyist)
IDENTIFICATION:
Form of Identification
Personally known (Principal)
SIGNATURE AND STAMP OF NOTARY:
of Florida, County of Miami-Dade
~ to a subscribed efore me
day of _~~~, 2(I/~
State of Florida, County of Miami-Dade
Swor d subscrif~d efore me
ThisO '~ ¢qy of ~Jl~t , 20 D g
of Public Notary -State ~7f F
on of Lobbyist's signature
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
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Annual Registration fee: [ ]Yes [ ] No Amount Paid $ 5~ ~++'~
MCR # Date Paid b
Lobbyist Registration Form received and verified b .
Revised 02/04/2008
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~,~I'K~ 1-po ~- ~ `~ ~ ~~-L~~ G~ e'2--'~
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 resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
Signa
Revised 02/04/2008
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Date: