Cynthia J. Brown - Miami Beach Gay Pride , IL,
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RECEIVED
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City of Miami Beach Office oV P ty Clerk
1700 Convention Center Drive, MitilirlietaEt,RN:SMF3UCE
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LOBBYIST REGISTRATION FORM
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Lobbyist means all persons employed or retained, wheth,r 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 pr ,cess on such
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or commit ee. The term
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclu ions. Please
refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I) I
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BU !NESS NAME' A , D ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: E v AIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY: , •
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME ADDRESS (Numbr and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] ,
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• NAME OF CHIEF OFFICER, PARTNER, OR BEhEFIClikRY:
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIREC LY, A 5% OR MORE OWNERSHIP INTEREST IN ,
SUCH CORPORATION, PARTNERSHIP, OR TRUST:
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II.SPECIFIC LOBBY ISSUE: ... i
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Issue to be lobbied (Describe in detail): ,
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III. CITY .AGENCIES/INDIVIDUAL! 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, .givinc 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 precedir g said City
personnel' commencement of service with he City to the present date, stating the general nature of the subject
contractual relation.
A) Full Name of Individual/Title 1 B) Any Financial, Familial or Professional Relation hip.
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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) Al (*.
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): /�
(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 OtisNo: Are you lobbying 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 Lobby sts On
Real Estate Deveiopment issues':
❑ Yes t_No: Are you 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 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 a not - for - profit
corporation or entity without specia 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.
1QSL Yes ❑ No: Are you 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 I LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECED . G CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURE '. OR OMPENSATION DURING THE REPORTING
PERIOD.
Signat e of Lobb ist `••
I do solemnly swear that all of the = -,oing facts are true an. •orrect and that I have read or am familiar with the
provisions contained in Section 2-4: • the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
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Signature of Principal /Client: i
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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y ,16 //O / &?4,14s.Produced ID 76
i ^ I Form of Identification Form of Identification
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Q = ° ❑ Personally known (Lobbyist) ❑ Personal) known Pr h
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P. Q i _ ' '�; -"4.' klY COMMISSION # DO 879891
* w z VII. SIGNATURE AND STAMP OF NOTARY: .k ='° .1
..,.,^ �::�:�.� = PIRES: April 13, 2013 rX
v� c`. 0: I , i ;:6, < °• oonded T lru Notary Public Underwriters
r lu State of Florida, County of Miami -Dade State of Florida, County of Miami Dade
Sworn to nd subscribed • -fore me Sworn a d subscribe• before me
ag This O 2010
. `,�,�,•�� >:� , � :ay of This l � day � � 07r: J
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* , ;g :' , ' ' S o' Public ot. -, — State o ' ""iida Signature of b lic Nota State of Florida
Notarizati • n of Lobbyist's signature Notarizatio of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY b
Annual Registration fee: [ r Yes [ No Amount Paid $ A. C # Date Paid // /e /D
Lobbyist Registration Form received and verified by: e
F;\ UR\ ALL\. Fo 7 s \Lo i T FORMS \Lobby t Registration Foam 2010,doc Revised 05/05/2010
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME:
I understand that no later than February 28th of each year, I must, file the following
form, 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 and Compensation 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 l egistered 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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Signa 0 Date:
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City of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida 33139 www.miamibeachfl.gov
DEPARTMENT - City Clerk' Office
Tel: 305/673 - 7411 Fax: 305/673 - 7254
ANNUAL LOBBYIST REGISTRATION FORM
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Name: � p y�
Business Name:
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Address: B7 3 Vv e ‘coq 51- , lo - 1-1 33 , b 2-
Phone: 7 g( 3 2- E ` �, 2 L
Email: e Ce sker sot, .CO P(/\
If more than one Lobbyist, please list:
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MCR #:
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Amount paid: 1\) 0� * f Date paid:
Processed. by: Date:
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F. \C ER\LOBBYIST\ obbvis!4nnua/ Regis/ration Form.doc
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