Roman Jones/Roach Holdings
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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 defined in any
manner in this section, 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 ftLobbyistsW has specific exclusions. Please refer
to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last)
CO
7t:-(M.I)
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(Zip Code)
(State)
FIIX NUMBER:
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I. LOBBYIST RETAINED BY:
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NAME OF PRlNCIPAl./CUENT:
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BUSINESS NAME NO ADDRESS (Number and Street) (City)
-€g.e;
he
PL ~~9
(State) (Zip Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c}l
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.
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIREffi Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: ~ .vet 12--'\Jq I ~ S::"\--~
II. SPECIFIC LOBBY ISSUE: ~ 4
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A} Full Name of Individual/Title
B} Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATI N (DISCLOSE WHETHER HOURL Y,
FLATRATEOROTHER). ~
A) LOBBYIST DISCLOSURE: (Required)
1) Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach Citv Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach Citv Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoalan Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST 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 C ALEND~R R. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITU CO NS ION DURING THE
REPORTING PERIOD. .
Signature of Lobbyist:
Signature of Principal/Client:
rreet and that I have read or am
i Beach City Code and all reporting
VI.
PRINCIPAL IDENTIFICATION:
l-J Produced ID
lJ Produced ID
Form of Identification
o4--Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Form of Identification
~SOnaIlY known (Principal)
Si ature of Public Notary - State of Florida
Notarization of Lobbyist's signature
Sig re of Public Notary - State of Florida
Notarization of Principal's signature
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... " Explrea June II, 2007
_______ FOR CLE~ ONLY
Annual Registration fee: ['--r'i'es [ ] No Amount Paid MCR t62~ ~=?S Date PaidS- t.f -t> 'F--
Lobbyist Registration Form received and venfied by:
Revised 02/10/04 F: CLER\ALl\MARIA-M\lOBBYIST\lOBBYIST FORM 04