Wyatt A. Porter-Brown - Surfrider Foundation~ m MIAMIBEACH ~''~~
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, 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.
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TELEPHONE NUNI6ER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
S 8 ~l~ 7? ~,T ~~l ~/~~ ~L 33) 38
and Street) (City) (State) (Zip Code)
(M.I)
LOBBYIST RETAINED BY:
BUSINESS
(Number
(city) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill
• 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:
II.SPECIFIC LOBBY ISSUE:
to
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482t9) 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 Title
~t~r~~.~r ~o~ ~T~ B) Any Financial, Familial or Professional Relationship
f't ~8 {~
IV. D-SCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): ,
A) LOBBYIST DISCLOSURE: (Required) ~ ~ ~'-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
i
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":
^ Yes IdJ N0: Are you lobbving on a present or pendinq bid for goods equipment or services or on a
present or pendinq 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 change to the Citv's Future Land Use
Map?
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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 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 any item, shall register with the clerk 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:
F'tKIC7D.
Signa of Lo ist
I do solemnly swear that all of the foregoing facts are tru and correct and that I have read or am familiar with the
provisions contained in Section X482 of the Miami Beach City Code and all reporting requirements. ,
Signature of Lobbyist: (/ /,(/ `~(
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA'
PRINCIPAL IDENTIFICATION:
,~'~' Produced ID F~~ t~C~G-~~.~?~ •Q
(v Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
Produced ID F.~L.~ ~~' ~~'~' ~~`~
Form of Identification _
Q. Personally known (Principal)
of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
i to i~d subscribed before me Sworn and subscribed befor me
o day of ~'r~~v 2010 This 1~day of , 2010
`~ L c ~
tur of Public No ry -State of Florida Signatur of Public otary -State of Florida
iza ion of Lobbyist's signature Notariz tion of Principal'sLsignatunnre ~.-
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY /tIO~iD~ Hie4~(~ ~ ,
Annual Registration fee: [~ ]Yes [ ] No Amount Paid $
Lobbyist Registration Form received and verified by:
F:\CLER\;ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form
Revised
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m /V~iAM!BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CiryClerk@miamibeachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME:
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.
AND FEE DISCLOSURE REPORT
Y. ANY LOBBYIST WHO FAILS
~ORT BY DECEMBER 1, SHALL
BBYING UNTIL ALL FINES ARE
1ST. In the event a lobbyist fails to
the Clerk shall notify the Miami-Dade
u ~ V THE MIAMI-DADE COUNTY
IN ADDITION, ONCE AN ISSUE 1 HAVE REGISTERED TO LOBBY ON HAS
BEEN RESOLVED, I AM REQUIRED TO IMMEDIATELY NOTIFY THE CITY
CLERK'S OFFICE OF LOBBYIST WITHDRAWAL tN WRITING.
5igna re: te: