Jane Gilbert/Arts for Learning
Mi;ami ..h
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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
Oty Manager or any dty board or committee; or any action, dedslon or recommendation of any city personnel 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 dty commission, or a dty board or committee. The term specifically includes the principal as well as any employee ellf/iJ(/f!d
in lobbying activities. The term "Lobbyists- has specific exdusions. Please refer to Ordinance 2004-3435.
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CUENT:
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(aty)
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FAX NUMBER: (Optional)
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(State) (ZIp ode)
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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: 10..0e.. ~\ \ \:Je ,* ...fi.e..~J <'-"':1
IDENTIFY ALL PERSONS HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: t'\ ~ _
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D. SPECIFIC LOBBY ISSUE: Rrb O~~$:lo,CDO-\o \m~ Ml.~:s. "'6~ ~~" ~~
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Issue to be lobbied (Describe in detail):
m. 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 COMPENSAnON (DISCLOSE WHETHER HOURL Y,
FlA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) . ~ -( \' 0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~e..rb
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":
o Yes ~io: Are vou 10bbvlnG on a Dresent or oendlnG bid for Goods. eaulDment or services. or on a
Dresent or oendinG award for Goods. eaulDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes "'" ""'.... Job4vioo gn a .....'00 ...._ for a Dolr.l!foament Aa_ with tile Qty :.
V aDDllcation for chanQe of zoninG maD desiGnation or chanGe to the CItY's Future Land U
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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-proflt
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..
Ives 0 No: Are YOU reDresentlnG a not-for-Drofit corooratlon or entity without sDecial comoensatlon
V or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OlY CLERK A SIGNED
STATEMENT UNDER OATH, UmNG LOBBYING EXPENDITURES, AS WELL AS COMPENSAnON
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHAU BE FILED EVEN IF THERE HAVE BEEN NO EXPENDI RES COMPENSAnON DURING THE
REPORnNG PERIOD. ....__.-.-----
VI.
o Produced ID
Form of IdentifICation
;t. Personally known (lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Form of IdentifICation
~ersonallY known (Principal)
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
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Signature of Public Notary - State of Florida
Notarization of lobbyist's signature
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,,) Expires AuguIt 01.2001
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This a of 20...1?J
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Signature of Public N ry - State of Florida
Notarization of Principal's signature
Amual RegIstration fee: [ \.] Yes [ ] No
lobbyist Registration Form received and verified b}l
F:\CLER\$AlL\MARIA-M\lobbyist\LOBBYIST fORM .
Date Paid f.crtc>-os
Revised 12/08/04