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City of Miami Beach Office of the City Clerk -3 AM 9: 25
1700 Convention Center Drive, Miami Beach, FL 3 y,NpEC .
LOBBYIST REGISTRATION FORM CITY CLERK'S OFFICE
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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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) 1 (State) ( (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL: rail - CO
Please' notify this office if. your contact information cli es address, phone, or e-mail address.
1. LOBBYIST RETAINED BY: -� /
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Nu er and S eet) (City) (State) ( (Zip Code
TELEPHONE NUMBER: FAX NUMBER: (Optional) r EMA : (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:
n SPECIFIC t .h�BBY ISSUE
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Issue to be lobbied 0 -s ribe in detail): .------1 ! "
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III. " CITY 3 A0ENCIES1INCIIVOUAtt TO BEIL r BBIEDYP rsuant 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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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) I - .
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPEN TIO a
(Required),. : , ; ). — 4„ e C. L
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 , i! No: 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 Lobbyists On
Real Estate Development Issues ":
❑ Yes : 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 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 #4 No: Are ou re • resentin • a not -for- • rofit co • o tion or entity without special compensation or
reimbursement..
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V. SIGNATURE UNDER -F . ' A
ON FEBRUARY 28th OF EACH YEAR E E A, LOBBYIST • ,ALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING L • = BYING 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 EXPENDITURES OR COMPE c ATION DURING THE REPORTING
1 PERIOD.
1
ignature o i Lobbyist
I do solemnly swear that all of the foregoing facts . e true and • rect and that. I have read or am familiar with the
provisions contained in Section 2-48 e Miami : - : ch City Code and all reporting requirements.
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Signature of Lobbyst" ` ''
Signature of Principal /Client' \ /1;14/ '
_ ,- LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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U .' �■'roduced ID C cp ' ` . '-'/ LO 61 roduced ID
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= g ,; Form of Identification Form f Identification ❑ Pers on al) known Lobb ist ❑ Personal) known Princi al ; 60 v� Y ( Y ) Y ( p )
w 4�' � MY CI ABEL
SI GNATURE AND STAMP OF NOTARY: Y mmissi0N # DD 879891 r EXPIRES: A
o �" Bonded Thru Not Public 2° Underwriters
Si of Florida, County of Miami -Dade State of Florida County of Miami-Li-
�,` r � `� / me _
?rn to and subscribes before me Sworn and subscrib-d before
- ate i
, z o _day of 10 This d of 1 _ , 2 0
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Signature • Public No' — tate of Florida Signatur of Public •ot -ry — State of Florida
Notarizati n of Lobbyist's signature Notariz tion of Principal's signature
TO BE COMPLETED BY CI CLERK'S STAFF ONLY
Annual Registration fee: [ ih‘s [ ] No Amount Pam h136 , CR # 30851/ Date Paid
Lobbyist Registration Form received and verified by: - 1 -3^,/ _� � c lte /i
F: \CLER \$ALL \aFORMS \LOBBYIST FORMS \Lobbyist Registration Form 2010.doc Revised 05/05/2010
/vUAMBEACH
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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: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST S2
lVI�ME.
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 registered to lobby on has been resolved, I am
required to immediately notify the City Clerk's Office of lobbyist withdrawal in
writing.
■:ir t
Sign.tur -: Date.
Revised 09/24/2010 - REP
F: \CLEP \LOBBYIST\Expenditure 8 . Disclosure Form Itr.doc
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic
community