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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 during the time
period of the entire decision-making process on such action, decision or recommendation that foreseeably win 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 "'I..oIJbJists .... specific exclusions. ........ to 0nIi..-c:e 2004-3435.
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r~RETAlNEDl i
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NAME OF PRIN CliENT:
33~ L{ (
(Zip Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership 01' Trust [Section 2-482 (e))
. NAME OF OiIEF OFFICER, PARTNER, OR BENEFICIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR lRUST:
SPECIFIC L<!.BBY I~: , .
( .,-\) , U ~\ I ~'\IY\
Issue to be lobbied (Describe in detail): '
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II.
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of IndiYidual/11tIe
B) Any Financial, FamiHaI 01' Professional Relationship
IV. DISa.OSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHElHER HOUR! Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINOPAl'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ 0 '
."D"
The following information must be answered:
1) Pursuant to Miami Beach Qty Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
o Yes '(NO: Are YOU lobbvina on a DreSeI'It or DendinG bid for GOOds. ecluiDment or services. or on a
oresent or oendina 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 10bbvinG on a ""dinG ilDDlication for a DevelODment AGreement with the City or
aDDlication for chanae of zonina maD desiGnation or chanae to the aty'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..
riyes 0 No: Are YOU reoresentina a not-for-orofit corooration or entity without soecial comoensation
or reimbursement. .
V. SIGNAlURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR,. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING 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 EXPEND RES 0 PENSATION DURING THE
REPORTING PERIOD.
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/Clien :
LOBBYIST IDENTIFICATION: / PRINCIPAL IDENTIFICATION:
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11 Produced 10 ~,. I ~/ ~ Produced 10 ri?/z~71J ~ ~
~ ~~den='3/~~5g7 Form of Idehtlfication
.J Personally known (Lobbyist) ~ 14,x,!1' .J Personally known (Principal)
VI.
VII. SIGNATURE AND STAMP OF NOTARY:
Annual Registration fee: [ ] Yes [ ] No
Lobbyist Registration Form received and v
F:\CLER\$AlL \MARIA-M\lobbyist\LOBBYI
State of Ronda, County of Miami-Dade
Sworn and SUbSCrib~ me ~
This -1.3-day of . 20~J
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Signature of Public Notary - State 0 'da
Notarization of Principal's si ature
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