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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 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.
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FAX NUMBER:
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LOBBYIST RETAINED BY:
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BUSINESS N~E AND ADDRESS
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TELEPHONE NUMBER:
(First)
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(City)
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(State) (Zip Code)
EMAIL:
C )057-(rJ A- CA-SfJ7)
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(City) (State) (Zip Code)
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(Number~ Street)
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FAX NUMBER: (Optional)
EMAIL: (Optional)
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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% 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
(l-UiMif S '10 ('</X) 1
/340 Ij~EY;f;l AvE
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WH
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":
ment or services or on a
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
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
se . n but, shall not be required to pay any registration fees..
DYes
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING 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 CO NSATIO NG THE
REPORTING PERIOD.
I do solemnly swear that all of the foregoing facts
familiar with the provisions contained i dic
requirements.
Signature of Lobbyist:
Signature of Principal/Clien .
VI.
D Produced ID
Form of Identification
/" rerue!
~Personally known (L~Jbtf' -DUc#'<\S~
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VII. SIGNAT=~t :<t:: ~.~~JVt:
:: :n:. .:f2:: . y,or&Ilv
State of Florida, C~~~~at#f-Bade
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Sworn to a~d subscnu~ e>ore me
This ';?D day of . d-- ' 20 ~
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
FOR CL
Annual Registration fee: Yes [ ] No Amou 'p'
Lobbyist Registration Form received and verified by:
F: \CLER\$ALL \MARIA-M\Lobbyist\LOBBYIST fORM 05.
at I have read or am
Code and all reporting
PRINCIPAL IDENTIFICATION:
o Produced ID
Form of Identification
~ally known (Principal) -e{'Oet
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State of Florida, C'" ~~~'1\'l1 Ok
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Sworn ~.f! subscri~ '.. . ~In~6.y.~,..-
This ~day of '" ~" tOg.>
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Signature of Public Notary - State of Florida
Notarization of Principal's signature
S~~~R # 6l7ft tit Date Paid
Revised 12/08/04