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City of Miami Beach Office of the City Clerk 'V~ /~1~
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
specrflcally includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific ezelusions. Please
refer to Ordinance 20043439~~
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS ( umber and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX BER: EMAIL:
I. LOBB ST RETAINED BY:
NA F PRINCI UCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section H principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: !K ~ ~, V • ~0'`~~St~-,
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OW rNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: I n~ /' „~'^,~.` ~ ~ ~ ~ ~~ ~ /'
n SPECIFIC~LOBBY ISSUE:
Issue to be lobbied (Descnbe in detail): - - - - --_
ul. CITY AGENDt~S/INDI\/tDUALS TO 'BE LOBBIED: Pursuant to City Code Section 2-482(8) include
_.. __
a statement of the extent of any business, flnanclal, fainilial~ professional or_ other, relationship, giving rise to an
appearance of an Impropriety wMh any City personnel sought to be lobbied ==further, pursuant to Clty Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said Clty
personnels' commencement of service with the Clty to the present date,, stating the general nature of the subject
contractual relation.
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ancial
, Famllial~or Professional Relationshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): J1 ~
(Required). ~.~~f~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
Own Procurement Issues":
^ Yes L1'No: Are you lobbying on a present or pending bid for goods eauiument or services or on a
present or pending award for goods, eauiument or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
• Real Estate Development Issues":
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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, shall register with the clerk as required by this
~sec~tion but, shall not be required to pay any registration fees.
^ Yes L`7 No: Are you rearesentina anot-for-profit coruoration or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of the foregoing facts are true and, n• and that I have read or am familiar with the
provisions contained in Section 2-482 of th~j~IGtiami Beach ' y Cod d all repbrting~equirements.
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Signature of Lobbyist:
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VI. LOBBYIST IDENTIFICATION: PRINCIP L IDENTIFICATION:
~duced ID r~ Produced ID ~~~a d
Form of Idenf _
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Form of Ident~cation ti ~ ~ d
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^ Personally known (Lobbyist)~~ g ~ _ ^ Personally known (Principal) Z
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VII. SIGNATURE AND STAMP OF Z
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State of Florida, County of Miami-Dade ~ o ° ~ State of Florida, County of Miami-Dade r W
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Sworn to andsubscrib b r me > "' ~ Swornnd
subscrib d of a me
This wN day of J~~~~, 2009 g ~ ,
Thi ~"Nday of , 2009 ~„~o'••.
Stkjrtrature f/Public Notary -State of Flori -~!~° Signature d~u is rp--Sta +,of Floes
Notarize ion of Lobbyist's sig ture ~'°";;;,;;t:'~'' Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
-- Annual Registration fee:. .]Yes [ J No Amount Paid $~~5~_MCR # 0/' Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\SALL\ar"P]RMS\LOBBYIST ECIRMS\Lobbyisi Registration Form 21209.tloc ~~ _Revised 02/11/
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Si atu of Lobbyist
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City of IWiami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: ~~5~ ~'~ ~~ ~-~
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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:
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F:\GE_ERILL~SBY#ST'\L.abbyist R®gistration harm 32?08.dac