Eric J. Brakken/SEIU Local 32BJ~ ~ E v« .t.y~. .
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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 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
specrfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
NAME OF LOBBYIST: (Last)
(First) (M.I)
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u.SPECIFIC LOBBY fSSUE
, NEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR I
NDIRECTLY, A 5 /o OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: f
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.SS NAME
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out this section if principal is a Corporation, Partnership or Tru
• NAME OF CHIEF OFFICER PARTNER OR BE
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I• LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
ul. CITY AGENCIES/INDNIDUALS TO BF iLOgBIEiD: Pursuant to City Code Section 2-482
a statement of the extent of any business, financial, familial, professional or other relationshi (g) include
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 T2 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
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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 COMPENSATION): ( J`
(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":
present or pendina award for aoods equipment or service?
~) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
J Yes I No: fare vu ~wv ~~~ ~~ ~ -••-• -
a lication for Chan a of zonin ma desi nation or than a to the Cit 's Future Land se
Man?
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.
ON OCTOBER 1ST OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH ~ w LISTING ~ cOnoBrNF p F('PEDING CALENDAR YEAR. A STATEMENT SHALL
PERIOD.
I do solemnly swear that all of the for
provisions contained in Sectio of the
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATI
roduced ID ~ 1
Form of Identificat
^ Personally known (Lobbyist)
Vll. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Sworn to~r~sub~ ribed b~ re me2009
This da of ~(
utilic Notary - to of F
of Lobbyist's signature
~-gigrratefe of LoBt1~8r
are true and correct and that I have read or am familiar with the
Beach City Code and all reporting requirements.
~ u PRINCIPAL IDENTIFICATION:
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Form of Identification ~.
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State of Florida, County of Miami-Dade yy
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" Sworn pa~n/~ subscribe efor me
2009
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Signatur Public No -State of Flori a
Notariz ion o rincinal's signature
BE COMPLETED BY
Annual Registration fee: [ es [ j No Amount
Lobbyist Registration Form received and verified by:
~`" ~#..=ka~e3Ft~'~iw~~'l~~s,~4~~€kW ,: -±tt~":~~:~4askr~Yaa
STAFF ONL
MCR # _ Date Paid
Revised 02/11/2009
V. SIGNATURE UNDER OATH:
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City of Miami Beath, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~~~ 1
CityClerk@miamibeachfl.gov
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.
Sig
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Date:
F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc