Michael J. Saks/Orange Bowl Committeem MIAMIBEACH
City of Miami Beach OfFce 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 dedsion-making process on such action, decision or recommendation that foreseeably will be heard or reviewed
by the aty commission, or a city board or committee. The term spedfically includes the principal as well as any employee engaged
in lobbying activities. The term "Lobr/b-~yists"has specific exclusions. Please refer to Ordinance 2004-3435.
~i4KS ~~ C!-IKI~L
NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHON NUMBER: FAX NUMBER: EMAIL: '
I. LOBBYIST RETAINED BY:
NAME OF
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
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TEL~E 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 BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTERESIC~N SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY
Issue to be lobbied (Describe in detail):
III. 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,
FLATRATEOROTHERJ: ~ ,
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
Dresent or oendina award for goods, eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Y A 1
aoolication for chance of zoning mao 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
"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..
or reimuursemenc. .
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.
Sign of Lobbyist
I do solemnly swear that all of the foregoing facts are true and orrect 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/Client: ~
VI. LOBBYIST IDENTIFICATION:
~( Produced ID ~S SASS ~I R ~
Form of Identificatiorlr
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This Z day of ~ ~ . 20`~t'
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
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PRINCIPAL IDENTIFICATION:
(Produced ID ~L ~~?iur,~ ~~CeNS
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This Z day of SgP i , 20 ° ~
Signature of Public Notary -State of Florida
Notarization of Principal's signature
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Annual Registration fee: [ ]Yes [ ] No Amours ~_ MCR # -~ Date Paid V ~V ~~
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc ~,~„ryK, Revised 12/08/04
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City of Miami Boach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww,miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fox: 305.673.7254
LOBBYIST NAME: ~ i'eN/~EL ~. ~:~kS
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 fife these forms on a timely basis will result in my name being transmitted to the
Miarrli-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, 1 am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
~--- 9 - 9'~ 08
Signature: Date:
i~~~visad 0?_l044r200S