Dennis Ward/Save No. Beach 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 pdndpal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or derision 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 dty personnel defined in any
manner in this section, dudng the time pedod of the entire derision-making process on such action, decision or recommendation
that foreseeably will be heard or reviewed by the city commission, or a dty board or committee. The term spedfically indudes the
principal as well as any employee engaged/ri lobbying activities. The term "Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
NAME OF LOBBYIST:
INESS NAME AND ADDRESS
TELEPHONE NUMBER:
,~La~ (First)
(Number and Street) (City) (State)
FAX NUMBER: EMAiL:
(M.I)
(Zip Code)
Ii LOBBYIST RETAINED BY:
NAME OF PRINCII:~L/CLIENT: --
BUSINESS NAME AND ADDRESS (Number and Street)
TELEPHONE NUMBER:
(ab/) (state) (Zip Code)
FAX NUMBER: (Optional)
EMA~L: (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 ~ SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II.. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
~ AGENCIES/INDIVIDUALS TO BE LOBBIED:
IA) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
DXSCLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATZON (DZSCLOSE WHETHER I'iOURL Yz
FLA T RA TE OR OTHER.,):.
A) LOBBYIST DISCLOSURE: (Required) _ ~ ~
B) PR/NCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required)..¢ ~
Y~~.' A "
re vou reore~entinn a n,~*-for--~r~fi· "'rr-r-~i-n - r --" ........ ~ '
n ~ w, n ca lC m'ensati nor
1) Pursuant to Ordinance No. 2003-3393 Amendin Miami Beach Ci Code ha ter 2 Article VI! Division 5
There f Enti led "Cam ai n Finan Re¢ tm" Vi Th A dition f Code e ion -488 Entitled "Prohi i e
Cam ai n ontri uionsB Lo bi OnProcur mnt! ues":
or n in w f r i n r i ·
:2) Pursuant to Ordinance No. 2003-3395 Amendin Miami Beach Ci Code Cha ter 2 Article V ! Division 5
thereof Entitl d "Cam ai n Finan e Reform" Via The A dition Of Code Section 2-490 EntiUed "Prohibited
Campaign Contributions By Lobbyists On Real Estate Development !ssues':
V. SZGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYZST SHALL SUBMTr TO THE cTrY CLERK A SI'GNED
STATEMENT UNDER OATH, I./ST]:NG LOBBY/NG EXPENDll'URES, AS WELL AS CO'NPENSAT]:ON
RECEI'VED, ]:N THE CTI'Y OF M]:AM]: BEACH FOR THE PRECEDZNG CALENDAR YEAR. A STATEMENT
SHALL BE I=]:LED EVEN ]:F THERE HAVE BEEN NO EXPENDI'TURES OR~R/NG THE
REPORTZNG PER/OD.
Signature of Lobbyist
! 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 ~
requirements. ~ Section 2-482 Miami Beach City Code and all reporting
Signature of Lobbyist: ~
Signature of Principal/Client:
vz.
LOBBYZST ZDENTZFZCATZON:
L-~roduced ID /Y~~ ~
Form of Identification
,r'~e~sonaIIy known (LobbyiSt)
S~[GNATURE AND STAMP OF NOTARY:
PR!NC!PAL ZDENT/F~CAT]:ON:
[] Produced ID
Form of !dentification
[] Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn to and subscribed.before me ,--
This ,~7 P~ __day .or .~, , 2Q2.~
ignature-,~'~f/pu'blic No~e of Florida
Notarization of Lobbyist's signature
ii .;:,,,~" ./'::~ '::~ ~,,,iY COMMISSION #, DO 17~91
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 Principal's signature
Annual Registration fee: [ ] Yes [ ] No Amo~ntJJ~
Lobbyist Registration Form received and verified by: "'7 J .__I___
Revised 02/10/04 F: ClJE~ ~ARIA-M\LOBByiSi~LOBBYIST FORM
Date Paid
2.0U3
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 dry personnel defined in any
manner in this section, 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 engagedin lobbying activities. The term "Lobbyists" has specific exclusions, Please refer
to Ordinance 2004-3435.
'~IA~E OF LOBBYIST: . (Last) (First)
. -
~S]NESS NAME AND ADDRESS (Number and 5~t) (Q~) (S~te)
'~PHONE NUHBER: F~ NUHBER:
(M.I)
(Zip Code)
EMAIL:
Z. LOBBYIST RETAINED BY:
NAME OF PPJN L/CHENT:
BUSINESS NAME AND ADDRESS u ber and Street)
TELEPHONE NUMBER: FAX NUMBER: (Optional)
(State) (Zip 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):
CITY AGENCXES/ZNDIVZDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
/.
.,_r "-
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER I"IOURL
· cia T RATE OR OTHER,):.
A) LOBBYIST DISCLOSURE: (Required) i
,,
I~) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).~
/x~l~Yes ~ No: Are you representinq a not-for-profit coroorati0n or entity without special c0mpens:=tion or
reimbursement. Pursuant to Ordinance No. 2004-343S. -
1)
[] Yes'~N0:
2)
DYes ~o:,,
V.
pursuant to Ordinance No. 2003-3393 Amending Miami Beach City code Chapter 2, Article VII, Division ~,
Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled"Proh~b~te(l' '
Campaign Contributions By Lobbyists On Procurement Issues":
Are yOU Iobbvina on a present or pendinq bid for goods, eouipment or services. Or on a prescnl
or oendinq award for goods, eaui0ment or service?
Pursuant to Ordinance No. 2003-3395 Amendinq Miami Beach City Code Chapter 2, Article VI! Division b
t_hereof Entitled "Campaign Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaign Contributions By Lobbyists On Real Estate Development Issues".'_
Are you lobbying on a pendina application fgr a Development Agreement with the City o,
aDDlicaUon for chanae 9f zoning mad desienation or change to the City's Future Land Use MAD:-
SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEARt EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATHt 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 COMPENSATION~DURING THE
Signature of Lobbyist
I 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 Beach City Code and all reporting
requirements. .~
Signature of Lobbyist: ~
Signature of Principal/Client: ~
:
VI. LOBBYIST IDENTIFICATION: ~ PRINCIPAL IDENTIFICATION:
~-~'~Prod uced ~D ~/~C~ ,~~ [] Prod uced T D
Form of Identification Form of Identification
~:~P'~ersonally known (LobbyiSt) [] Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dado
Sworn toaod subscdbe~before me
This .~.,7/-~ day ~f _/~~ , 2Ct.?S
~ig~ature-.~pu'blic Nota~~- e of Florida
Notarization of Lobbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This .... day of ,20~
Annual Registration fee: [ ] Yes [ ] No Am
Lobbyist Registration Form received and verified by:
Revised 02/10/0~
Signature of Public Notary - State of Florida
Notarization of Principal's signature
Date Paid
FOR,~LERK'~i USE a~ I
kLOBBYIST FORM Oq