Herbert W. Anderson, Jr.~Mn ~AfL lG l TTtnn ~~ t~v 111~L.
1 ~ ~ ~:
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 speck exclusions. Please
refer to Ordinance 2004~t35.
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BUSINE NAME AND ADDRESS (Number and Street) (City)
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NUMBER: FAX NUMBER: EMAIL:
. 33 13
(Zip Code)
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIE T: // ,~-"
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BUSIN SS NAME AND ADDRESS (Number nd trget) (City) (,State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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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 INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.S'PECtFIC 'LOBBY ISSUE:
-~ . , _.,,
to be lobbied (B scribe in detail):
uI. CITY AGENCIES/fNDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise 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 said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
Full Name of Individual Title
A B) Any Financi I, 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)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSF~IQTV):
(Required). ~~CCJJ
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 L7 No: Are you lobbying on a uresent or uending bid for goods eauipment or services or on a
present or nendina award for goods eauipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
~ •
^ Yes ~ No: Are you lobbying on a pending application for a Development Agreement with the Citv or
application. for change of zoning map designation or change to the City's Future Lend 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, shalt register with the clerk as required by this
section but, shall not be required to pay any registration fees.
^ Yes Flo: Are you representino anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
nwl nnTil~rr. .ST ..~ r..... ...
ECEIVED. IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR A STATEMENT SHALL
QC GII GA GVGwI Ir Turr~r
PERIOD.
Lobbyist
I do solemnly swear that all of
provisions contained in Section
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
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'CJ Produced ID Dr. C~'t#, ~~ a 93~
Form of Identifica ion
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAM
State of Florida, County of Mi
Sworn to and subscribed before ~ ~~
This ~~day of q ~2 ,
Signature of Public Notary -State of ~
Notarization of Lobbyist's signature
ARY:
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and that I have read or am familiar with the
~~orting requirements.
PRINCIPAL IDENTIFICATION:
1~"Produced ID ~~.L~°c~ `1JL ~t/q/g3 `~
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dai
Sworn a subscribed before me
This day , 2009
. _ • _ ,
5fgnature of Public Notary -State of Florida
Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: Yes [ ] No Amount Pa' $ MCR # Date Paid 2J D ,
Lobbyist Registration Form received and verified by:
~c~E~~~a~~.°~~~oi~s~~.c~as~'~s~ ~~~nb~i~~ e_ s~ ~~ae~r~ ar~r+, ~.~~,~~~: Revised 02/11/2009
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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
LOBBYIS N ~
I understand t~,at 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 registered to lobby on has been resolved, I am required
to immediately notify t ity erk's Office of lobbyist withdrawal in writing.
natu
Date:
F:\CLER1LCt1w3BY1Sll~obbyist Registration Form 327Q8.doc