Karen M. Peterson~~~ ~~ 4 L~-~ ~~ ~~
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 mod'rfication of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
Ciiy Manager or arty city board or committee; or any action, decision or recommendation of any city personnel during the time period
of the entire derision-making process on such action, derision or r~ec:ommendation that foreseeably will be heard or reviewed by the
city commission, or a aty board or committee. The term specltic;aly includes the principal as well as any employee engaged !n
bbbying activities. The term "Lob lets" has specHic exclusions. Please refer to Ordinance 2004-343ti.
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1. LOBBYIST RETAINED BY:
BUSINESS NAME AND ADDRESS (Number and Street)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Tru
• 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 LO BY ISSUE: ~' " l `-``~ `- ~ I r
C ~. R ~r~R-~l-'l A~.l G ~ .5 c~. F' 1~-
issu to be lobbied (Describe in detail): Q
111. CITY AGENCIES/INDIViDUAi.S TO BE LOBBIED: ~~ Z~ 9
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A) Full Name of IndividuaUTitle ~ B) Any Financial, Familial or Professional Relationship
(Last)
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURtY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ..~ O „~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): -.~ ~ .,._-
(Requlred).
The following information must be answered:
1) Pursuant to Miami Beach Gity 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
"IobbyisY' as set forth in Section 2-481 above) who onty appears as a representative of a not-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 Gerk as required by this
section but, shall not be required to pay any registration fees.
t~Xes ^ Na: Are you representins>I a not~'or-profit corporation or entity without special compensation or
reimbursement. .
V. 31tiNATURE UNDER OATH:
ON OCTOBER 7sT 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 O CO NSATION DURING THE REPORTING
PERIOD.
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Sig ature of Lobbyist
I do solemnly swear that all of the foregoing facts are true a rrect and that I have read or am familiar with the
provisions centained in Sedion,2-4~? of the N)iami Bach City Code and all reporting requiremerrts.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
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~oducedlD
o Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This day o~~,~, 20~
>'E~lic.~tate of Florida
of Lobbyist's signature
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PRINCIPAL IDENTIFICATION:
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oduced ID .~
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Form of Identificatio
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^ Personally known (Principal) ~ ~
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gag State of Florida, County of Miami-pad ~
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~ w ~ Swom a~n~,Isubscribed fore me a
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of
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ !U°'~~~°e ` ~,eo
MCR # Date Paid ~-- ~ d g
Lobbyist Registration Form received and verified by: ~
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
Tel: 305.673.7411 ,fax: 305.673.7254
CityClerk@miamibeachN.gov
LOBBYIST NAME: ~~ °~~ ~ so v~
I understand that no later than Ober 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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Signa re: te: