Amy Perrym ^~`,I;'a ',I BEACH
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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 prinapal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or deasion of any commissioner, any action, deasion, 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 deasion-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 prinapal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
NAME OF LC/~BYIST: ~
YYlD~1-Si nu.i (Last)
yKcdi auk C-eh. ~, (First)
~(3c~ 14-~I~, (M.I)
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BUSINESS NAME AND ADDRESS (Number and Stre ) (City) (State) (Zip Code)
3 0 5 (~~-~-[. -a s 2v
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
E AND ADDRESS \ (Number and Sheet) (City)
NUMBER: FAX NUMBER:
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:
n.SPECIFIC LOBBY ISSUE:
~.~. ~ ahd.vu~l~ur~e,
nl. CITY AGENCIES/INDIVIDUALS. TO BE LOBBIED: (Pursuant to City Code section 2-as2(91
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(a)(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 B) An Financial, Familial or Professional Rel
ations
hip
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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 LOBBY T 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":
^ Yes ~No: Are you lobbving on a present or pending bid for goods, equipment or services. or on a
present or pending award for goods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues':
application for change of zoning map designation or change to the Citv'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 snot-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 corre
provisions contained in Section~l82 of the Miami B~'ach City Code a
Signature of Lobbyist:. '
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
,~,~ Form of Identification
IJ Personally known (Lobbyi
VII. SIGNATURE AND STAMP ~. 1`i4~F
State of Florida, Count of Miami-D ~~~'~
Y
Sworn to and subscribe before me
This ay of , 2
ignature of Public Notary -State of Florida
Notarization of Lobbyist's signature
that I have re#i~or am familiar with the
:porting requ ents.
PAL IDENTIFICATION:
0 Produced ID
Form of Identification
.r....~...~ y known (Pri , ~ PRISCILLAFRIEDLAND
PRISCtLIA FRIEDLAND ~ ~;= MY COMMISSION # DD 543864
hfY COMMISSION # DD 543864 ~~ s;= EXPIRES: August 23, 2010
EXPIRES: August 23, 2010 ''~,'~;~d,S• - Bided ThN Naary Public Uoderniitere
BondedThNNotaryP da, COUnty O
w rn an subscribe before me
This/ day of , 200
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY C TY C RK'S STAFF ONL
Annual Registration fee: ]Yes [ ] No Amount S - MCR # ate Paid
Lobbyist Registration Form received and verified by.
F:ICLER\1.Q$$YIST\i.obi~yist Registration Form 3270$.4 Revised 03/27/2008
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, voww.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: /" ~ W1 ~~r~L
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.
i
(p 2 G
Signature: Dat
F.IGLEF2t[_OBBYIST1Lobbyist f2egistratian Form 32708.c1oc