Isabel Chattas/Fox Pan American
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F(ECEfVED
City of Miami ~~~TOffk:ePff~E3q;ity Clerk
1700 Convention C~~~r ,priY~(<Miami Beach, FL 33139
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LOBBYIST REGISTRATION FORM
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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 tenn "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First)
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BUSINESS NAME AND ADDRESS (Number and Street)
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TELEPHONE NUMBER:
(City)
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FAX NUMBER:
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(State)
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EMAIL:
(M.!)
33/31
(Zip Code)
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAljCUENT:
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BUSINESS NAME AND ADDRESS' (Number and Street) (City)
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TELEPHONE NUMBER: FAX NUMBER: (Optional)
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. (State) (Zip Code)
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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:
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· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. S~ECIFlC LOBBY ISSUE:
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to be lobbied (Describe in detail):
CITY AGENCIES/INDMDUALS TO BE LOBBIED:
II Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
.A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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.
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 ~o: Are YOU lobbyina on a Dresent or Dendina bid for aoods. eauiDment or services. or on a
Dresent or Dendina award for aoods. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes
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..
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 PENDITURE C PENSATION DURING THE
REPORTING PERIOD.
Signature of Lobbyist:
I
Signature of Principal/Clie
VI.
Iid""'Produced ID ''j)L e '6ZL -<.fOO-05--5-rtf-- D 0 Produced ID
Form of Identification I Form of Identification
o Personally known (Lobbyist) 'personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn t~l1ClsubSCribed before me _
This Udayof ~i,. .2005
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Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
Signature of Public Nota -
Notarization of Principal'
FOR CLERK'~_USJ: ONLY ,
Annual Registration fee: r /] Yes [ ] No Amount Paid ~ MCR # 2~o Date Paid Jcf2/(hs
Lobbyist Registration For" re~eived and verified by:, ~~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05~oc Revised 12/08/04