Claire L. Tomlin„~..,,. _
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City of Miami Beach Office of the City Clerk pQ qq~~~~~~~ 29 ~~ ~. ~
1700 Convention Center Drive, Miami Beach, FL ~3~3~
LOBBYIST REGISTRATION FORM
Lobbyist means all persons empbyed or retained, whether paid or not, by a princpal 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 sty 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 foreseeat>fy will 6e heard or reviewed by the city commission, or a city board or committee. The tens
specificaly includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" tree specific exclusions. Please
refer to Ordinance 2004343b. I _
EMAIL:
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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:
II.SPECIFIC LOBBY ISSUE:
to lie lobbied (Describe in detail):
ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: PursuarK to City Coda Section 2-482(g) include
a statement of the extent of arty business, financial, familial, professional or other relatlonship, giving rise to an
appesrence of an impropriety with any City personnel sought to be bbbied -further, pursuant to Cky Cods Section 2-
482(ax4) include a statement of any contractual relationship (paid or unpaM) from 12 moms preceding said City
personnels' canlrienccemnerrt of service with the CKy to the present date, stating the general nature of the subject
corttracdial relation.
A Full Name of Individual Title B) An Financial, Familial or Professional Relationshi
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I. LOBBYIST RETAINED BY:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) l.~e'
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
The following ir>formation 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 lobbl-incti on a present or pendirui bid for goods. equipment or services. or on a
present or oerMi~ awaM 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 ~ No• Are you lobbving on a oending application for a Dsvelopmert Anreement with the City or
ap.lication for chance of zoning map designation or change to the City's Future Land Use
M- ao?
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 only 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 clerk as required by this
section but, shall not be required to pay any registration fees.
_^_ Yes ~t No• Are you repr~esentina a not-for-profit corooration or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of the foregoing facts are true and correct and that 1 have read or am familiar with the
provisions contained in Section 2-482 of the iami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ~rUf~/~ ~-t.C,P.~~ Produced ID VY1.V~av'5 ~.~~n a~
Form of Identification Form of Idgn ' cation ( O
"rrJ~ 5 l l Z `t- 3 X24 . b ~" `j ~C ~ l l 2- ~' 3 ~ ~'
~ ^ Personally known (Lobbyist) ^ Personally known (Principal)
g ~~ 11. SIGNATURE AND STAMP OF NOTARY: ~ 8 ^~
~ ~~ tate of Florida, County of Miami-Dade State of Florida, County of Miami-Dade ~ ~~
wom to an~subscribed befo me Swom and subscri befo a me
his ~ day of .Se 2009 This~day of 200 a~
Sign ure of Public otary -State of Florida Signa ure of Public Not -State of Florida ~~.~~,
Notarization of Lobbyist's signature Notarization of Principal's signature =~'~
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY =~~; •~
Annual Rson fea: Yas [ ] No Amount Psld; ~ R • 5 Dabs Paid
Lobbylst Ra~ngon Fornt ncalvrd and variflad tiy: A- ~ ~°
F:\CLER\$ALL\aFORMS\LOBSYIST FORMS\tAbbyist Registration Form 211Q9.dot Revised 02)11/2009
Signature of Lobbyist
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachH.gov
CITY CLERK Office CilyClerk~miemibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: G~11('t° TOYYt~f 1-~
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.
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Signature: Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc