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City of Miami Bead 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 4decisWi-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 p iflc exclusions. Please refer to Ordinance 2004-MS.
NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (NumbVW Street)- (City) } (Zip Code}
IS3 S
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
1. LOBBYIST RETAINED BY:
in
NAME OF PRINCIPAUCLIENT: & ��� �C�t � � � a b o v
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (gip Code)
TELEPHONE NUMBER: _�b4 AX NUMBER:(Optional) EMAIL:(Optional)
Fill.out#ds section If prindpat is a Corporatlodv Partnership or Trust[Section 2482(c)}
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 506 OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
ii.SPECWIC LOBBY ISSUE.
Issue to be lobbied(Describe in detail): 2L-36-� 3
III.WY AGENCIES/114DIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2482(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 enerai 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
Pursuant to City Code Section 2482(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 24V2fM Any Financial Familial or Professional Reb0onship
' i1W m
F:ICLERI$ALL1aF0RMSIL0BBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCL SE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
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":
_Yesv_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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
evelopment 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 Section 2-482(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.
VYes—No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 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 EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami B ch City Code d all r orting r uir ents.
Signature of Lobbyist:
Signature of Principal/Client: Rol
VI. LOBBYIS IDFtN,11FICATION: PRINCIPAL IDENTIFI TI N:
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orm of tdentif �� ,.°••°• �i Form of Id tcat�,q� pia,,
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Personally known(Lobbyist) Personally known(o P ne• 22 �° 0� �•o
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VII. SIGNATURE AND STAMP OF #EE191409 °C--,z
(a C191
State of Florida, County of Miami-Dade ��i��''�r�°�°Bh 1�°°' ��' X� State of Florida,County� arti ,�ade 9
or an subscMefore '''i00o iee, ��0��\``\ Sw�o a nd aubofri r '• ' �0'�\Nis day o 8111 y 0,``\���' 1 ign ure Public a gna re o Public Notary— tate of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by:
_..b; .. Revised 01 22 2014 f':1ari.xe 8 VIST >%ta' l
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