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City of Miami Beach Office of the City Clerk 3° - 33-~j/~D3
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
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.
Dy`c~1u~4-~J ~-~ 1'~
NAME OF LOBBYIST: (Last)~,p (First) (M.I)
BUSINESS NAME AND ADDRESS (Nuwrber and Street) (City) (State) (Zip Code)
ELEPHO OBBY STER~~ ~ B~~~ ~ ~~ . ~ ~. ~~ / ®EMAIL:
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NA E OF PRINCIPAU LIENT:
BUSESS NAP AAE At~]~DDRES ~ ~~~lu~rtber and Street) (City) (State) (Zip Code)
FAX
EMAIL:
a
or
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC .LOBBY ISSUE:
Issue o be lobbied (Descnbe In detail).
iii. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) 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
personnel' commencement of service with the City to the present date, stating the general nature of the `subject
contractual relation.
A Full Name of Individual Ti
le B) Any Finan
cial, Familial or Professional Relationship: ~ ;
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fV. DISCLOSURE OF TERMS AND ANTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLATS
RATE OR OrHER):
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A) LOBBYIST DISCLOSURE: (Required) ~" ~ L..~ ~~ /// ~`
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B) PRINCIPAL'S DISCLOSURE (,~F_LOBBYI T COMPENSATION)
(Required). A ~J.('~-,~ ~-
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":
^ Yes t!'J" No: Are you lobbying on a pending app{ication for a Development Agreement with the City or
application for change of zoning map designation or change to the Citu's Future Land Use
Mau?
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.
^ Yes B No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
Signature of Lobbyist:
Signature of PrincipallClient:
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
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~producedlD ~~SJ`--r~l~-6y""~~-C3 0 ProducedlD
Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
Form of Identification
^ Personally known (Principal)
tote of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
worn to and subscribed before me Sworn and subscribed before me
his ~.`" day of , 2010 This day of , 2010
Sig!- r~ of u is Notary -State of Florida Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
' TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid p,
Lobbyist Registration Fonn received and verified by: ~
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc Revised 05/05/2010
I do solemnly swear that all of the fore oing facts are true and correct and that I have read or am familiar with the
provisions contained in Sectign 2~82,el~he Miami Beach City Code and all reporting requirements:
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m MIAMIBEACH
City of Miami Beaeh, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME: ~f ~~ ~~ / C' ~~ ~ ,
I understand that no later than October 1st of each year, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar year with regard to .the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have .been no expenditures or
compensation during the reporting period. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
Failure to timely file the expenditure and fee disclosure report will result
in a fine of $50.00 per day. Any lobbyist who fails to file the required
expenditure report by December 1, shall automatically be suspended
from lobbying .until all fines are paid, unless the fine has been appealed
to the Miami-.Dade County Commission on Ethics and Public Trust. In the
event a lobbyist fails to either file the report and/or pay the assessed fines, the .Clerk shall
notify the Miami-Dade County Commission on Ethics and Public Trust.
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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: