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~.' M A: 50 City of Miami Beach Office of the City Clerk
05 M" Y 26 A 1700 Convention Center Drive, Miami Beach, FL 33139
C"\"'''- '.-' , E'Gr'!'C:: OFFICE
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LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a prindpal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or dedsion of any commissioner; any action, decision, recommendation of the
City Manager or any dty board or committee; or any action, decision or recommendation of any dty personnel defined in any
manner in this section, during the time period of the entire decision-making process on such action, dedsion or recommendation
that foreseeably will be heard or reviewed by the dty commission, or a dty board or committee. The term Specifically indudes the
principal as well as any employee engaged in lobbying activities. The tenn "Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last)
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BUSINESS NAME AND ADDRESS (Number and Street) (Oty)
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\ TELEP NE NUMBER:
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(First)
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(M.I)
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(Zip Code)
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FAX NUMBER:
(State)
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EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINOPAL/CUENT:
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BUSINESS NAME AND ADDRESS (Number and Street)
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LEPHONE NUMBER: - FAX NUMBER: (Optional)
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'331"12
(Oty) (State) (Zip Code)
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EMAIL: (Optional)
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Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFACER, PARTNER, OR BENEAOARY:
. IDENTIFY All PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.
SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS 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,
FLA TRATE OR OTHER): _____
A) LOBBYIST DISCLOSURE: (ReqUired) ~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
1)
Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City CO:: Chanter 2. Arti~le VII. DiVi~ion 5
Thereof Entitled "CamnaiQn Finance Reform" Via The Addition Of Code S ion 2-488 Entitl d "Prohibit d
Camoaion Contrlbution~ Bv lobbvls15 On Procu7"ent I~es': _
A'll YOU 10bbvinG QD · ~~ Gr ~:G .id far aqds. llfluioment or senril;lll. or on i Df'ISeOt
or DendinG award for GOods. eGuiDment or service?
DYes ~
2)
Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chanter 2. Article VII Division 5
thereof Entitled "Camnaian Finance Reform". Via The Additi~n Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions By LobbYists On Real Estate Develo ment Issues":
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SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG 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
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. r:7J A _ ~ ~
Signature of Lobbyist: ,~~ ---- (
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
o Produced 10
Form of Identification
o Produced 10
Form of Identification
Y Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
o Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This _day of , 20_
.,
Signature of Public Notary - State of Florida
Notarization of Principal's s.!gnature
FOR
Annual Registration fee: [ ] Yes [ ] No Amou
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F:
L\MARIA-M\LOBBYIST\LOBBYIST FORM 04
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