Carol Coombes/Miami Gay/Lesbian
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City of Miami Beach ,?ffice 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 decision-making process on such action, decision or recommendption that foreseeably will be heard or reviewed
by the city commission, or a city board or committee. The term specifically includes thepriricipal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST:
Coot-1B~
(Last)
Cl\(Lo L
(First)
m1tVll"L (62\ Pr.(;r~ ~. ~l4.7
(Number and Street) (City)
3:D - 53S -- ~ 31-1-
FAX NUMBER:
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EMAIL:
(M J)
331~
(Zip Code)
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I. LOBBYIST RETAINED BY:
..-l:1l:fitj\ ~M + ~I~ filJl\ fL~'Tlv'f\L. 1~C-.
NAME OF PRINCI~10clIENT: .
(State)
3311>1
(Zip Code)
'521 AL:loN 1\i:> .
BUSINESS NAME AND ADDRESS
3o'j 5:>4,. qq 2-
~)4l
(Number and Street)
HIA"MI ~
(City)
R-
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (e}l
. NAME OF CHIEF OFFICER, PARTNER, OR BENEACIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTL Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
CUL7J(ftc 7oU((ISM 6f<MT
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
14111111 8e1iGH V C'pr NONE .
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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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":
D Yes ~NO: Are YOU lobbYinG on a Dresent or Dendin9 bid for Goods. eGUiDment or services. or on a
Dresent or DendinG award for Goods. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes .,. No: Are YOU lobbyinG on a Dendina aDDlication for a DeyeloDment AGreement with the City or
aDDlication for chanGe of zoninG maD desiGnation or chanGe to the City's Future Land Use
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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..
JiYes 0 No: Are YOU reDresentinG a not-for-Drofit corporation or entity without sDecial comDensation
or reimbursement. .
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 COr,tPENSATlON DURING THE
REPORTING PERIOD. (\ C . I
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Signature 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. (\ (\ I
Signature of Lobbyist: ~ ... \.-OOAA b~ 1
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICA
PRINCIPAL IDENTIFICATION:
II Produced ID
II Produced ID
Form of Identific~tion
>< Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Form of Identification
~e.r.sonaIlY known (Principal)
FOR CLERK'
Annual Registration fee: [ ] Yes [ ] No Amount Paid
Lobbyist Registration Form received and verified b .
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MCR #N:J(\ ? fc ate Paid ~ 23
Revised 12/08/04