Timothy Todd Martin/Marx Realty & Improvement CompanylG ~/ C~~o ~ ~`
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City of Miami Beach Office of the City Clerk ~' w
1700 Convention Center Drive, Miami Beach, FL 33139 - - ~.._.--
LOBBYIST REGISTRATION FORM u`> ~~-~
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or n~ficatiQ{Dof ;°~
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city boartl',pr
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on ~
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee.~he t2fiii
specifically 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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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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Issue to be lobbied (Describe m detail):
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nl. ;CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2.482(8) include
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a statement of the extent of any business, financial, familial, professional or other relationship, gluing rise to an
appearance of an impropriety with any Clty 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) An Financial, Fam111a1 or Professional Relatlonshl
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATS OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~D~ ~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): rr ,~
(Required). -` ~ V ~ ~1/~ '
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 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 chance 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 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
section but, shall not be required to pay any registration fees.
reimbursement. .
V. - SIGNATURE UNDER OATH:
Signature of Lobbyist: ~ + ~/ (/' j' f1~r/~G
Signature of Principal/Client: ~_~ ~ }~' Q„~, ~,,,,~{'-
VI. LOBBYIST IDENTIFICATION:
produced ID Q',/1,Lrh.t',{/'
Form of
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Sworn o a subscribe before e
This ~_day 9f 00
of~gllic Notary -State of F
0 of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
_ Produced ID _~~~2~(i
Form of Identification
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° M ~ ^ Personally known (Principal)
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~ State of Florida, County of Miami-Dade
~ ~ Sworn a,~d subscrib before me
,•~i~~c.,,. This/•~/ day ob 09
Sigf`ii3fure~f Pubfis-Pletacy~. _~late of FI
Notarization of Principal's signature
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TO BE COMPLETED BY CI CL 'S STAFF ONLY
Annual Registration fee: [ ' Yes [ J No Amount Paid $ '""-MICR # Date Paid
Lobbyist Registration Form received and verified by:
F.\CLER\$ALi.\aFORMS\L08BYI5T FORMS\LObbyist Registration Form 21109.doc Revised 02/11/2009
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in S ion 2 82 of the Mi~rr~l Beach City Code and all reporting requirements.
. ~ MIAMIBEAC{ 1
City of Miami 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: ~~~ ~g~~N
I understand that no later than October 1st of each near, 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:IGLERILOBBYIST1Lobbyist Registration Form 3270$.doc