Michael ToomeyMiami Gay and Lesbian Film Festivalm G ~~'" 1
MIAMI~EACH ~ ~~' ~
~,
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 prinapal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner, any action, deasion, recommendation of the City Manager or any aty board or
committee; or any acton, decision or recommendation of any city personnel during the time period of the entire deasion-making process on such
action, deasion or recommendation that foreseeably will be heard or reviewed by the city commission, or a atY board or committee. The term
specifically inGudes the prindpal as well as any employee engaged in lobbying activities. The term °Lobbyisffi" has speclflc exclusions. Please
refer to Ordinance 2004-3435.
NAME OF LOBBYIST: .(Last) (First) (M.I)
and Street) (City) (State) (Zip
~'ts ~ N ~ 2 ~~ ~o~ 'M ~,ar,r;, ~ 33~ 3~
TELEPHONE NUMBER:3~_~y~~~~ FAX NUMBER:.~~ S~-a-•3~~ EMAIL: `~(1~e ~~\,~1~ ~ ~,M
Please notify this o>~ce if your contact information changes: address, phone, ore-mail address.
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
M \Cx~tr~~ C\ c.,-1 '4~r1 Oi L+~S~1CxY1 ~ ~ ~ ~~S'h ~ ~n
BUSINESS NAME AND ADDRESS (Number an Street) (City) (StateL (Zip Cod;) $
NUMBER:
is a
or
~~3~~
~'t ~• Lc~vl~
• 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: N 1~
II.SPECIFIC LOBBY ISSUE;
C~~~,.~.5, ~bV•`~~~SM~ C~Ya.~n~ " ~3t~~~n~ ~c~w:~- ~~~ J~4h T1 `~'C'~YW'1,
Issue to be lobbied (Describe to detarq:
ul. ;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 Clty 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.
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FAX
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSU E (OF LOBBYIST COMPENSATION):
The following information must be answered:
1) Pursuant to Miami Beach Ciry Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues°:
^ Yes ENO: 'Are you lobbvinq on a present or pending bid for goods equipment or services or on a
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 ~ No: Are you lobbvinq on a pending application for a Development Agreement with the City or
application for change of zoning map desionation or change to the Citv's Future Land Use
Man?
3) Pursuant to Miami Beach Ciry 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 Gerk as required by this
section but, shall not be required to pay any registration fees.
Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: ~/Tl
_ _ ____~ Signature of Principal/Client
VI. LOBBYIST IDENTIFICATION:
~~
g ~ ~ ~ Produced ID ~N~.ps~~ ~ O~i(:6$a ~~
a °` ~ Form of Identification
~~
~ ^ Personally known (Lobbyist)
~ ~ VII. SIGNATURE AND STAMP OF NOTARY:
~roduced ID
Form
^ Personally known
~tate of Florida, County of Miami-Dade
wpm to and subscribed before me
his ~~{Y~ day of c~ n1 ~ 2010
Signature of)Zublic Notary -State of Florida
Notarization of Lobbyist's signature
~ TO BE COMPLETED B
Annual ReglstreUon fee: [ ]Yes [ j No Amount Paid
Lobbyist Registration Forn received and verified by: _
F:\CLER\SALL\aFORMS~LOaevTCT cnnMC~ ~ ,.tip..:,.. ~__:_~__~
DEL 3ATLyf
~' ~Nh11SSI0N A DD 879891
EXPIRES: ~I 13 2013
Bonded=~ PuDlic Undena(fers
State of Florida, County of Miami-Dade
Swom and subscribe befo me
This l~day f ~1~ 01
Signature of~ ublic Notary -State of Florida
Notarization of Principal's signature
Revised 05/2/2010
pv~ fae. ~~iT
Paid D
ign tune of Lob pst
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or m miliar with the
provisions contained in Section -482 of the Miami Beach City Code and all reporting requirements.
„_
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachN.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME: _ (r~t~no.-e_~ ~~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-DADS 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.
IN ADDITION, ONCE AN ISSUE 1 HAVE REGISTERED TO LOBBY ON HAS
BEEN RESOLVED, 1 AM REQUIRED TO IMMEDIATELY NOTIFY THE CITY
CLERK'S OFFICE OF LOBBYIST WITHDRAWAL IN WRITING.
~\~sl~~
Date: