Steven N. Adkins~ r~"~'~."J,IBEACH
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, declsion, 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 decisiorrmaking 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 arty employee engaged in lobbying acti "es. The tens "Lobbyists" has specific excl sions. Please
refer to OMinance 2004-3435.
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BUSINESS NAME AND ADDRESS (Dumber and Street) (City) (State) (Zip Code)
FAX
1. LOBBYIST RETAINED BY,
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EMAIL:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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out this section if principal is a Corporation, Partnership or Trust [Section
• 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:
IS~IUE:
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Issue to be lobbied (Describe in detail):
uL :CITY.AG'ENCIE~S/INDI~/IiDU'. TOB:E LOBBIED: Pursuant to City Code Section 2-48 g) include
a statement of the extent of any busin financial, familial, professional or other relationship, giving se to an
appearance of an impropriety with any City personnel sought to be lobbied -further, pursuant to City Code action 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from t2 months preceding aid 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):
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A) LOBBYIST DISCLOSURE: (Required) ,(~ ,~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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The following information must be answered: 9"~'~~'
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 ~-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues": '
application for chanae of zoning map designation or chanae 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 ahy item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
reimbursement. .
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V. SIGNATURE UNDER OATH:
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I do solemnly swear that all of the foregoin f s are tr "and correct an~fhat I have read or am familiar with the
provisions contained in Section 2-4 a is i Be City Code and all reporting requirements.
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Signature of Lobbyist:
Signature of PrincipallClient:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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Produced ID/~ ~~ -711 5']-L99-(~ ~ Produced ID ~~J`~-79~ J`~`~-~g /-~
Form of Identification Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribe b~ef~e me
This ~_day of St~~'- ice-x.2009
Signaturebf Public Notary -State of Florida
Notarization of Lobbyist's signature
Annual-Registration fee: [~] Yes [ ] No Amount
Lobbyist Registration Form received and verified by:
~a\CLER\S`ALL\aPORl1fS\i.O$BYIST EARNS\Lobbyist Reg
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribe befpre me
This day of 7` , 2009
Signature~of Public Notary -State of Florida
Notarization of Principal's signature
ITY GLERK'S STAFF ONLY_ /~/ ~~'/~~/~
MCR f ~- Date-Paid
Form 222 ci.doc ReVISed i
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
C iiyC I erk@ m i a m i be achfl . g ov
LOBBYIST NAME: ~v'~~, ~~ ~~ ~ r~ S
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 t e City Clerk's Office of lobbyist withdrawal in writing.
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Signatur Dat : .
f=:\CL.ER\1.O86YRST\Lobbyist Registration f=orm 32748.doc