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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 ftLobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
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NA~C'~~~ 1:'TAC~19. A.. ::J (First)
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
305'- 350-('1 fj.-o go Y1iiO-t(jQo
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TELEPHONE NUMBER:
FAX NUMBER:
(M.I)
MIAM.Il ~'-- -:?JI3J
(State) (Zip Code)
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EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND AD RESS
30'5" - gG,%~ ~~O'O
C'\-'a..l..t< MI~W\i
(Number and Street) (City)
E~~ I PL
(State)
33/'1/
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c))
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: J (At i~ th~.. Ie. te.r->A.c..'"
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: J t.c.l ,'c t +L Ie I.c..po. c.. h
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SPECIFIC LOBBY ISSUE: f'<\ ~/'I.u"'4..T7'U"" I
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Issue to be lobbied (Describe in detail):
II.
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
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 HOURL Y,
FLAT RATE OR OTHER): 11 Q:J.. I / I ~ 1.n
A) LOBBYIST DISCLOSURE: (Required) ?;:) ~.....
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Re~Uired). ~ 3...{ 5 / h. 0 t..l. r
Yes
ion or
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
rvices or on rent
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
Yes
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 CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. ~/(l. i5!L---
Y;gnature of Lobbyist
I 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 Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
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VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
D Produced ID
/ Form of Identification
'~r50naIlY known (Lob:'yi~)
o Produced ID
Form of Identification
[I Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to 'mc,"-~ f
Thi~Of _ 20!2r
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and sUbscr~~ be~ me
This~da of .6 ,2 D/,
~'I\ Chriatins CoItIns
. ~ . My Commission 00058838
\;. ~ Expires September 23,2005
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FOR
Annual Registration fee: [ ] Yes [ ] No Am u
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F. Cl
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.