Donna Carofano/Atlantic Broadb. 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 t~he passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendaUon 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, 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 dry board or committee. The term specifically includes the
principal as well as any employee engaged/n lobbying activities. The term "Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435.
INAME OF LOBBYISt: ...~Last) mm m (First) . f (M.I)
BUSrNESS NAME AND ADDRESS (Number and Street) (Ci~) f. J.~tate) I~[, j'l I/ ~ Co(Je)l
I., LOBBYIST RETAINED BY: . ·
'~AME OF P~NQPAqCUEaT: ......
BUSINESS NAME AND ADDRESS (Number and Street)· (Ci~)
-~ELEPHoNE NUHBER:
(State)
FAX NUMBER: (Optional)
(Zip Code)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] '
NAME OF CHIEF OFFIC~A_R. TNER, OR BENEFICIARY' )
IDEN~ ALL PERSONS HOLDING, D~E~Y OR IND~RE~LY, A 5% OR MORE OWNERSHIP ]NTERE~ ~N SUCH
COR~ON, 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/TiUe .
B) Any Financial, ~amilial o~Of~---T~ifll~nship
.
ZV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATZON (DZSCLOSE WHETHER I'iOURL Y~
FI. A T RA TE OR OTHER~..
A) LOBBYIST DISCLOSURE: (Required) 0
0
B) PR/NCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required) ....
~o: Are you representing a not-for-profit corporation or entity without special compensationl or
[]
Yes
[]
· reimbursement. Pursuant to Ordinance No. 2004-3435.
l)
OYes E~o:
2)
V.
Pursuant to Ordinance No. 2003-3393 Amendinq Miami Beach City Code Chapter 2, Article VII, Division ;,
Thereof Entitled "Campaiqn_ Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibiters' ~
.Campaign Contributions By Lobbyists On Procurement Issues":
Are you lobbying on a present' of pending bid for goods, equipment or services, or on a presenl
or pending award for goods, eauioment or service?
pursuant to Ordinance No. 2003-3395 Amending Miami Beach City Code Chapter 2, Article VII Division
thereof Entitled "Campaign Finance Reform.", Via The Addition Of Code Section 2-490 Entitled "Prohibite{I
Campaign Contributions By Lobbyists On Real Estate Development Issues"'
Are you lobbying on a pending application for a Development Agreement with the City o~
application for change of zoning map designation or change to the CitY'S Future Land Use Map:_
SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR~ EACH LOBBYZST SHALL SUBM:I:T TO THE CITY CLERK A STGNED
STATEMENT UNDER OATH~ LZSTZNG LOBBYZNG EXPENDZTURESz AS WELL AS COMPENSATION
RECETVED~ IN THE CZTY OF MIAM! BEACH. FOR THE PRECE'DZNG CALENDAR YEAR. A STATEMENT
SHALL BE FTLED EVEN IF THERE 'HAVE BEEN NO EXPENDZTURES OR COMPENSATZON DURING THE
REPORTING PER~OD.
// ~' ~'- Signatur~/6f Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have r. ead or am
con ' Sectio 2-482 of the lVl~am~ Beach' City Code and all reporting
requirements. .
Signature of Lobbyist: .
Signature of Principal/Client:
LOBBYIST IDENTZFICATION:
Produced ID
FoFm of Identification
~Personally known (Lobbyist)
PRINCTPAL IDENTIFICAT:]:ON: ' Il
Produced :ID
Form of Identification
Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscrib, g_d before rrke ~ ' '.
This ~ day of~
Signature of Public Notary .-.. State_Qf~Florida
Nora ~r, GG,;; :~-signatt~re .
: ~E~~ ~~_~.,'~'
~lllllilllllellllllel~lillellellllliel~lielel
State of Florida, County of Niami-Dade
Sworn and subscribed 'before me
This ... day of ,20__
Signature of Public Notary - State of Florida
Notarization of Principal'S signature.,
· .//~ FOR CLERK'S USE ONLY
Annual Registration fee:.. Iv j Yes [ ] No Amount Palp~t~ ~ MCR # -~L:~i~ Date Paid
Lobbyist RegistraUon Form received and verified by: '
Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBBYIST~LOBBYIST FORM 04