Ian H. Smith
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 prinripal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or derision of any commissioner; any action, derision, recommendation of the City Manager or any dty board or
committee; or any action, decision or recommendation of any rity personnel during the time period of the entire derision-making process on such
action, deasion or recomrr~ndation that foreseeably will be heard or reviewed by the rity commission, or a rity board or committee. The term
sperifically indudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Plsase
refer to Ordinance 20043435.
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NAME OF LOBBYIST: (Last) (First) rJ~ ~~. (M.I)
BUSINESS NAME AND ADDRESS ~ (Num er and Street) (City) (State) (Z' Code)
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I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:~~ ,5/'9/~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail): '
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-asz(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(x)(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
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C~~' QT'ej" 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):
A) LOBBYIST DISCLOSURE: (Required) ~~ ~~~ ~,l
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMP NSATION
(Required). ~Q ~~~
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":
^ Yes ~ No: Are you lobbvina on a present or uendina bid for goods, eauioment or services, or on a
present or pending 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":
^ Yes ,1~ No: Are you lobbvina on a pending application for a Development Agreement with the City or
r application for chance of zoning map designation or change to the City's Future Land Use
Map?
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:
I do solemnly swear that all of the foregoing facts are true and correct and ve read or am familiar with the
provisions contained in Section 2- a Miam' ch City Code and all re ing re 'rements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ~~I~~f$ ('« _ ~ Produced ID
Form of Identification
^ Personally known (Lobbyist)
Form of Identification
^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to nd su sc ~b fore me
~ /l , 2008
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TO BE COMPLETED BY
Annual Registration fee: [ Yes [ ] No Amount Paid ~
Lobbyist Registration Form received and verified by:
Fc~~(.E~€fATt,~Farr~t~~~cz~t3yist Reistr~ticsra Etsrsn.doC
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Principal's signature
Paid
Revised
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 . Fax: 305.673.7254
LOBBYIST NAME: .;%~~ S~"~/TiZI
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.
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Sig re Date:
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