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City of Miami Beach Office of the City��
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' J . 1700 Convention .Center Drive, Miami " 'FL 33139
LOBBYIST REGISTTION ORIVLt,,a,:
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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 ADbRESS (Number and Street) (City) (State) ! (Zip Code
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TELEPHONE NUMBER: . FAX NUMBER: EMAIL: •.
Please notif , this office if our information chap es. ;• address ;hon - : or- a -mail addr..'es _. ` Y s' ,
i. LOBBYIST RETAINED BY
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS. NAME AND ADDR Sp (Number and Street) (City)/ (State) (AptCodi
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional}' r--,
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-4 (c)] - ;) O , '
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIAR J v. r. c n
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY,OR INDIRECTLY, A 5% OR MORE OWNERSHIP IJsITERESIN SOS H CORPORATION,
PARTNERSHIP OR TRUST: , if-1
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ii SPECIFIC LOBBY ISSUE'
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2- 482(a)(4) Full Name of Individual and . ,Contractual Relationship (Explain) YES NO
title of person to be lobbied
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Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) 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) +ldV ) 9
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST C ?tlt7at' SATION :
(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 No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a present or pending
award for goods, or service ?, 1•;r 4"41 { t } s, 4 c) A lEis
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
,, , , p Issues
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r] Yes 'No: Are you lobbying on a pending application for a Development Agreement with the City or application for
r v 1 N • , ii, A ,- tchajicse,of zoni:nu maixdesignation or ohange.to t e City's °Future Land Use Map'? $. x 1,.- r -'� " A
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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 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 No Are you representing a not - for - profit corporation or entity :withbufiesp@plal oom.pensa~ti ti.•oY'I eimbursement.. .
V. SIGN TURE L NDER OATI : y ! p a • {
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ON FEBRUARY 28th OF EACH YEAR, '^e. EACH LOBBYIST SH SUBMIT TO THE C } ITY CLERK A SIGNED STA 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 EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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Signa is
1 do solemnly swear that all of the foregoing facts are true n corre, and that I have read or am familiar with the provisions contained
in Section 2 -482 of the Mi i B Cit Co e and all repo • g requi -ments.
Signature of Lobbyist: Lk -
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID 4%. G [-II-43'i- (3,5 ❑ Produced ID
Form of Identification •Form of Identification
❑ Personal) known Lobb ist ,, ® ❑ Personally known (Principal)
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VII. SIGNATURE AND STAMP OF NOTtY \ SS � o N • ' / � � 0 � ° ` %•
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State of Florida, County of Miami -Dade ' � : ®o., `� State of Florida, County of Miami -Dade
Sworn to and subscribed before me +o� . #DD 832367 • p Sworn and subscribed before me
This 47 day of , 2011 9`° dry �le;• This day of , 2011
�1�i -1 B4l STATEO F a ,"
nature of Public Nota — 4 :tate'of Florida ` � �� E � s Ni filll l t , � ° �� � Signature of Public Notary — State of Florida
Notarization of Lobbyist's ignature Notarization of Principal's signature `
TO BE COMPLETE BY CITY CLERK'S STAFF ONLY
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Annual Registration fee [ =],Yes[; ° ] No : Amount Paid $ "< d :MC # D ®: ' Date -Paid ��
= Lobbyist Registration:° Form received and ,verified by ,
ter:.
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City of Miam i Beech, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl : gov
CITY' CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 ,'Fax: '
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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 registered 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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