Stewart Stewart/CAC funding~€, ~` It ~ `
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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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 specific exclusions. Please
refer to Ordinance 2004-3435.
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY:
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
NAME OF LOB YIST: (Last) (First) (M.I) ~ ~Gd ~ r ` ~ t ~ ~.
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BUSINESS NAME AND ADDRESS (Number and Street) (City) State) (Zip Code)
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NAME OF PRINCIPAUCLIEN
BUSINE NAME AND ADDRE S Numb d Street) ity) (State) (Zip Code) ~
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:
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n.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
nl. CITY AGENCIES/INDIVLDUALS TC BE LOBBIED: Pursuant to City Code Section 2-482(8) 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.
A Full Name of Individual Title 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)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST 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 lobbvinq on a present or pendina bid for aoods 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":
^ Yes l~ No: Are you lobbvinq on a pending application for a Development Agreement with the Citv or
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.
~.. Yes ^ Na: Are you representing anot-for-profit corporation or entity without special compensation o_r
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
Signature of Lobbyist: Gam'
Signature of Principal/Client: ~ V" '~'
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID _ ~5~3`7 ~~` T ~ ~a~O^~ ^ Produced ID S 363" 70 G '"ya'~~6 ~ ~
Form of Identification Form of Identification r"~
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to ar~subscribe~ befor me
This day of tt~~ , 2009
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
^ Personally known (Principal)
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State of Florida, County of Miami-Dade ;;;
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Sworn and subscribe befo me
This /~o day of
2009 a ~
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Signature of ublic Notary -State of Florida ?;~``~~ `~
Notarization of Principal's signature ~°.?
TO BE COMPLETED BY CITY K'S STAFF ONLY ~~
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ Date Paid
Lobbyist Registration Farm received and verified by:
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I do solemnly swear that all of he foregoing facts are true apd correct and that I have re d or am familiar with the
provisions contained in Sectio~2-48~ of the Miami beach City Co¢~'~! all reporting requi~ments.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vwvw.miamibeachfl.gov
CITY CLERK Office CityClerkCmiamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
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LOBBYIST NAME: -' ~' ~ t.c~ ~ ~~ ~ ~
understand that no later than October 1st of eoch vTea_r, 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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Signature: Date:
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