Claudia Urdaneta/Mia World Th. 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 dty board or committee; or any action, dedsion or recommendation of any city personnel during the time
pedod 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 spedfically includes the principal as well as any employee engaged
in lobbying activities. The term ~Lobbyists' has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First)
BUSINESS NAME ~D ADDRESS (Numar and Strut) (Ci~)
~ELEPHO~ NUMBER: F~NUMBER:
(M.I)
(State) (Zip Code)
EMAIL:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS
TELEPHONg NUMBER:
(Number and Street) (City)
FAX NUMBER: (Optional)
(State) (Tip Code)
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:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CzlY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
~V. DZSCLOSURE OF TERf4S AND AHOUNTS OF LOBBYIST COf4PENSAT~ON (DTSCLOSE WHETHER HOUR£ Y~
FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
[~ Yes ~/No: Are you Iobbvina on a Dre-~e-nt or Dendina bid for aoods, eouioment or services, or on a D _r~_ qt or ~endina award for aoods, eouioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes 1~/No: Are you Iobbvina on a ~endina aoDlication for a Develooment Aoreement with the City or
apn~'_,ca~_'_on for chanoe of zoninq man de~.a~on or chan~e to the CitY's Future Land Use
MaD?
3) Pursuant to Miami Beach City Cede 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..
~Yes[~ No: Are you reDresentinq a not-for-profit corporation or entity without sDecial compensation
or reimbursement. .
V. SZGNATURE UNDER OATH:
ON OCTOBER Is~ OF EACH YEAR, EACH LOBBY[ST SHALL SUBIqZl' TO THE CTrY CLERK A SZGNED
STATEf4ENT UNDER OATH, LZST~NG LOBBYING EXPENDTFURES, AS WELL AS COMPENSATZON
RECEIVED, ZN THE CTrY OF f.l~d~l! BEACH FOR THE PRECEDZNG CALENDAR YEAR. A STATEMENT
SHALL BE F~LED EVEN [F THERE HAVE BEEN NO ~X~ENDTI'URES OR COMPENSATION DURING THE
REPORTING PER~OD. (~.~_ ~
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-q82 of the Miami 8each City Code and all reporting
Signature of Lobbyist:
Signature of PrincipalJClient:
LOBBY][ST TDENT~FZCA'rZON:
PR~NC2PAL IDENI'~FLCAT[ON:
Produced ID
~ r~ Form of Identification
~,~ ~ ~ ~ [] Personally known (Lobbyist)
~ ~ =~l/~Z, SIGNATU~ AND ~AHP OF NOTARY:
~ .m ~ ~te of Florida, Coun~ of Hiami-Dade
~ ~ '~ S~om tol~ sub~ri~ ~f0re me ~
~m ~is dayof ,Jd~ .20__
¢~'i'~fiz~on of ~bbyi~s sign~um
[] Produced ID
Form of Identification
[] 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 Prin~c~al', signature
/" FOR CLERICS USE ONLY///~/'t///'C~-~ '
~nual R~i~a~on f~: [ ~]~ [ ] No ~ou~ ~ ~ /)~ MC~ / ~ate Paid/_
Lobbyi~ R~i~ation Fo~ ~eiv~ and verifi~ by: ~ ~ ~/
F:~CLER~$~L~NA~-N~Lob~i~LOBB~ ~RH 05.~ ~ Revi~