Gail Seroth/Miami City BalletMIAMI'BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST RE GISTRATION 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, derision 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
/n lobbying activities. The term '1.ebbybl~' has ~pedf'ic exclmlena. Please refer te Ordinance 2004-343S.' .
NAME OF LOBBYisT: (Last) -- (F-~rst)
BUSINESS NAME AND ADDRESS (Number and Street) (City) ~ ' (State) ' (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYLqT RETAINED BY:
NAME OF PRINciPAL/CLIENT:
BU.S~N~ NAME AND ADDRESS x I (Number and Street) t (C'ty)
'ii~LEPHONE NUMBER: FAX NUMBER: (Optional)
(Z~p Code)
EMA[L: (Optional)
out ebb a~;~n if i,,;..¢;~a; b a Car-pa,allen, Pmtaerahip or Truer [Settion 2-482 (c)]
NAME OF CHIEF OFI~CER, PARTNER., OR BENEFICIARY:
'
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
CITY AGENC~ES/]NDIYZDUALS TO BE LOBBZED:
Full Name of IndividUal/Title
B) Any Financlal~ Familial or Profeamional Relationship
~-.ITLI
C.,rI
IV. DZSCLOSURE OF TERNs AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER/YOUR/.
FLA TRA TE OR OTHER~.
The following information must bu answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Con~butions By Lobbyists
On Procurement [ssues":
[] Yes IfNo: Are you lobbvin~ on a present or oendina bid for aoo~__, ecluipment or servi_-~_, or on -
present or.pendima award for ,oods, eauipment or service?
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Peal
Estate Development [ssues":
DYes J~No: Are. you Iobbvin. on a pending application .for a Development A--reement with the City or
· aDDlicaUon for chan~e of zoniml map desianafion or change to the City's Fu_h_,re ~d U,s,~
HaD?
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..
D Yes I~No: Are you renre~enting a not-for-Profit corporation or entity without s _l),~_.'al compensak-~n · or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SZGNED
STATEMENT UNDER OATH, ITST~NG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECPTVED, TN THE CITY OF HIAMZ BEACH FOR THE PRECEDZNG CALENDAR YEAR. A STATEMENT
SHALL BE FZLED EVEN ZF THERE HAVE BEEN NO EXPENDI'i'URES OR COiqPENSA-rZON DURZNG THE
REPORTING PERIOD. f,~ ~--
. '"//~ '~i~natb~e'"of Lobbyist
/ /
I do solemnly swear that all of the foregoing facts a!~true and correct and that ! 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: T,,~' bt~
Signature of Principal/Clien .~.. .
VL LOBBYZST IDENTIFICATION: PR~NCTPAL IDENTIFICATION:
Produced ID _] Produced ID
Form of Identification Form of Identification
/Personally known (Lobbyist) ~ersonally known (Principal)'
VZZ. SZGNATURE AND STAMP OF NOTARY:
State of Rodda, County of Miami-Dade State of Rodda, County of Miami-Dade
Swom tg~and subscril~d before me .. ~ :. Swom~:l subscribed before m
T~s6 ~. d, ay o~ 20.~N~ This ~a~ of ~~_ ~,~'!
/::~"~
Signa~re of PLfOh ta -~ State ~ ·
~i., ~o.o,..K.'.s u~.~.o.~~ '~' ~ , .,-~
.A.,n.u.) ~..~.o.. ~: [V'] ~.[. -:] ,o' "' Ar"ou..t~a L~. ,, .c. # ~1-~ D,~. ,.,d .~7--/D.d'O%
LOD~/~S~ ~eg~adon form receiveo ano verified by: .,~---'A'~_~
F:\CLER\$ALL\NARIA-N\Lobbyist\LOSBYIST lORN 0S,'Td& Revised Z2/08/04