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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 lime period of the entire derision- making process on such
action, decision or recommendation that foreseeabiy 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 2004-3436.
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NAME OF LOBBYIST: (Last) (Fi (M.I)
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BUSINESS NAME ANItl ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX UMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:
Iht, ('.r11 rn' SC) OM 1 - pi
NAME OF P NCIPAUCLIENT:
The ITaIM N * t 3025 Colhlrs eve. Kam f;cl, +�t. 33N 0
BUSINESS NAME AND AD MSS u mber and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill 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:
i.SPECIFIC;LO ISSUE:
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Issue to be lobbied (Describe in detail):
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 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 B) Any Financial, Familial or Professional Relationship
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N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $ 15O
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): i5-0 0
(Required). !
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 pi No: Are you lobbying on a present or pendinq bid for (roods, 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 fa No: Are vou lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
Map?
_3) Pursuant to Miami Beach City Code. 2484 (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 a not - 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 DA►No: Are vou representing a not-for-profit corporation or entity without special compensation or
reimbursement .
• V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL. AS COMPENSATION
RECEIVED. IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPEND! RES OR COMPENSA DURING THE REPORTING
PERIOD. r , •
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Signature of Lo yist
I do solemnly swear that all o the foregoing facts are true and co ct and that I have read or am familia with the
provisions contained in Secti • 2-482 of the Miami c - ach City Cod and all reporting requirements.
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Signature of Lobbyist:
Signature of Principal/Client: A Ai■ ` ii
VI. LOBBYIST IDENTIFICATION: ° - / IPAL IDENTIFICATION:
❑ Produced ID -- -- - - - -- - ❑ Produced ID
Form of Identification Form of Identification
Y!? blic State of Florida , , .fi P ty Notary
L9 Perso = II • L L�J" Personally known (Princi I ry Public Sta of Florida
• c My Commission DD757038 f Alma P Cue
VII. SIGN :• 4'•f,; SETi ORMIT21RY: •gc My CommissionDD757038
M ort Expires 02/0!2012
",_ State 'of of Florida, y ounty of Miami - ■ ade State of Florida, County • Miami - s a • e
Sworn to: and subscribed • of • re me Swom and s - cri • ed • e
-
This .M of it �ts� 2010 This Zc7 ., • 0.4.1 ! , 2010 ' •
. . SI"'re o public Mary - State of Florida Signs ure o Pubic •tary - State of Florida -
Notarization of Lob . 1 fist's sig ature Notarization of Prl i • , I's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY /
Annual Registration fee: [ j Yes [ j No Amount Paid $ 35a -- M R of - / • ate Paid /l/ Z
Lobbyist Registration Form received and verified by: 1 I- l
F: \CLER \$ALL \aFORMS \LOBBYIST FORMS \ Lobbyist Registration Form 2010.doc , o Revised 05/05/2010