Mitchell Bierman/M. Samuel 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 dty 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 dty commission, or a city board or committee, The term specifically indudes 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 Street) (City) ' (State)
(M.I)
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADD~ESS
(Number and Street) (City) (State)
TELEPHONE NUMBER: FAX NUMBER: (Optional)
EMAIL: (Optional)
(Zip Code)
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'aetail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
ZV. DXSCLOSURE OF TERHS AND Alq.~uNTS OF LOBBYIST COIqPENSAT~ON (DXSCLOSE ~...c-I'HER HOUR£ Y~
FLA T RA TE OR OTHER,):. '
A) LOBBYIST DT$CLOSURF: (Required) ~/{"~ ~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST corqPFNSAT~ON): (Required). ~-(,O~ ~'~t"
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":
[] Yes ~o: Are you Iobbyin,q on a present or ~)endinQ bid for Qoods, equipment or service~i or on a
present or pendin,q award for ,qoods, equipment or service?
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Tssues":
uYes ~'~o: Are you Iobbyin.q on a Dendin; aD=lication for a Development Aqreement with the City or
a==lication for chan,qe of zonin,q map desi,qnation or chanqe to the City's Future Land Use
Iqap?
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..
[] Yes ~No: Are you representin,q a not-for-profit corporation or entity without special compensation
or reimbursement..
V. SZGNATURE UNDER OATH:
ON OCTOBER Is'r OF EACH YEAR~ EACH LOBBYTST SHALL SUBI~ITr TO THE cTrY CLERK A SZGNED
STATEMENT UNDER OATH, LI'STI'NG LOBBYI'NG EXPENDTrURES, AS WELL AS COMPENSATZON
RECEZVED, ZN THE CZI'Y OF t4ZAF41' BEACH FOR THE PRECEDTNG CALENDAR YEAR. A STATEIqENT
SHALL BE FTLED EVEN ZF THERE HAVE BEEN NO EXPENDTrURES OR COIqPENSA'rZON DURZNG THE
REPORTZNG PERZOD.
Signature of Lobbyist
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:
~/'Produced ID~~~iml~lm''~ -,~..~Produced iD ~
~~'~l- ~- ~ ~-~rm of Zde~tifi~tion Fo~ of Zden~ifi~tion
u Personally known (Lobbyi~) ersonally k~wn
..... B~uc~MP
LILLIAN A
State of Florida, Coun~ of Miami-Bade~~~-- ~~ Florida, Coun~ of
Sworn to and sub. rind before me~~______
~is ~ ~ day or~e~~ 2~~0~:~' ~ ;..:_;Sworn ;and sub~rib~ ~fore me
}~;' ~is ~ day of~e~,,V~OO~
Signatur~of ~ublic Nota~/- S~te of Florida
No~rization of ~rincipal'~ ~ignatum
/' FOR C L E RI~'I~U.~E,.,0~N LY
Annual Registration fee:-t NfJ Yes [ ] No Amount Paid 1 ;.~,i.~--- r, lCR ~~~ Date Paid [~l~~
Lobbyi~ Regi~ration Fo~ mmiv~ and verified by: ~~ - -- -
F:~CLER~$ALL~NA~-N~Lobbyi~LOBBYI~ ~RN 05.d~ Revi~ ~2/08/~