JoAnn Arnowitz/Jewish Museumhli~rni Borsch
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 dudng the time
period 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 specifically 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 AND ADDRESS (Number and Strect~ (City) '
TI~LEPHONE NUMBER: FAX NUMBER:
(M.I)
(State)' (Zip C(~e)
EMIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINES~ NAME AND ADDRESS (Numbcgr and Street) d (City) '(State)
, b
TELEPHONE NUMBER: FAX NUMBER: (Optional)
(ZiI~ Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°~0 OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
Any Financial, Familial or Professional Relationship
ZV. DZSCLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATION (DZSCLOSE WHETHER HOURI.Y~
Fur RATE OR OTlfER~
A) LOOBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURI: (OF LOBBYIST COPIpI:NSATION): (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":
/
/
~1 Yes ~J~o: Are YOU Iobbvino on a ore----~-:qt or uendino bid for ooods, eauioment or
services,
or
on
a
oresent or oendina award for ooods, eouioment or service?
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
2) Es~/te' Development Issues":
/
E]Yea [~: Are you Iobbvino on a uendino aoolicat!on for a Develoument Aoreement with the City or
aoolication for chanoe of zonina moo desia~_at!on or chanoe to the City's Future Land Use
MaD?
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 2-48! 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
sect irect, to express support of or opposition to any item, shall register with the clerk as required by this
ion but, shall not be required to pay any registration fees..
~esD No: Are you reor~ntino a not-for-profit coruoration or entity without
soecial
comoensation
9r reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sz OF EACH YEAR, EACH LOBBY[ST SHALL SUBMZT TO THE CTrY CLERK A SIGNED
STATEMENT UNDER OATH~ I.zs'rZNG LOBBYING EXPENDTrURES~ AS WELL AS COMPENSA'rZON
RECEZVED~ IN THE cTrY OF MZAM! BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FZLED EVEN IF THERE HAVE BEEN NO EXPENDTrURES OR COMPENSA'rZON DURZNG THE
REPORTING PERZOD.
Signature of Lobbyist
T do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
Signature of Lobbyist: -
Signature of Principal/Client:
VI. LOBBY[ST IDENT~FICA'I/ON:
PR/NC/PAL ZDENT[FICA1/ON:
[] Produced ID [] Produced ID
Form of Identification Form of Identification
[~Personally known (Lobbyist)
i~l~ersonally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn te~and subsc-fibe~efore me .~.w_or_n_and subscribed before me
~/'~'/~J ~~~i'2~c~2~u~;~)f~Public Nota~' State of Florida
Sij~ature of ~Jublic Notary - State of lolling_ _NOT~¥ ~L N~ O, _.~..r~a.o.r~ ,~ -
I~otarizatio~ of Lobbyist's signature ...... of Principal's signature
. FOR/~:LERK'~ USE O~LY
Annual Registration fee: [ ] Yes [ ] No /~n~pa~--- ~_ ~ MCR # _ ~ _ ~
Lobbyist Registration Form received and verified la'y;" ~
F:\CLER\$ALL\MARL6.-M\Lobbyist\LOBBYIST fOR6~'0~ Revised ~2/08/04