HomeMy WebLinkAboutClaire Callen/Ocean-Fairwind MIAMIBEACH
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 city personnel during the time
pedod 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 term ~Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last)
BUSINESS NAME AND ADDRESS (Number and Street)
TELEPHONE NUMBER:
(First) (M.I)
(Ci~) (S~te) (Zip Code)
FAX NUMBER:
EMAIL:
I, LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
(Number and Street) (City)
FAX NUMBER: (Optional)
(State)
(7ip 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: ~, j~O~lJe ~ ~i~,/~.r.~) !/t~ ~~ ~
IDENT[FY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST I~ SUCH ,.,
CORPORA'I-ION, PARTNERSHIP OR TRUST: OC~.~ I.~ ~I~.~O ~ , ,/~J' C. ~lOt~d
SPECIfiC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CiTY AGENCIES/INDI~/ZDUALS TO BE LOBBIED:
iA) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
Iv. m$CLOSURE OF TER.$ ^ND ^.OUNTS OF ~O~ CO~.S~O" (mSC~OS~ W~~ ~ ~
~ r ~ ~ o~ o~
A) LOBBYI~DISCLOSURE: (Required) ~ N ~ O~~ ~ ~~ ~~~~
B) P~NCIPAL'S DISCLOSURE (OF LOBBYI~ COHPENSA~ON): (Required), ~ON~ ~ ~ ~ ~~~
The following information mu~ be answered:
1) Pumuant to Miami Beach CiW ~de Se~on 2-488 Entitled "Prohibited ~mpaign Contribu~ons By Lobbyi~
On Procurement I~ues":
~ Yes ~o: Are you Iobbvin~ on a present or pendinq bid for Goods, e~uipment Or se~i~es~ or on a
present or pendinq award for qoods~ equipment or ~e~i{e?
2) PurSuant to Miami Beach CiW Code 2-490 Entitled "Prohibited ~mpaign Contributions By Lobbyi~ On Real
E~ate Development Imues":
BYes ~o: Are You Iobbvin~ on a Dendino aDolication for a Development Aureement with the Ci~ or
application for chanue of zonin~ mad desi~naUon or chan~e to the Ci~'s Future Land Use
Nap?
3) Pumuant to Miami Beach CiW Code 2-484 (h) Any pemon (except those exempt from the definition of
"lobbyiA" as set foRh in Se~ion 2-481 above) who only appears as a represen~tive of a not-for-profit
co'rporation or entiW without special compensation or reimbursement for the appearance, whether direr, or
indire~, to express suppoK of or opposition to any item, shall register with the clerk as required by this
se~ion but, shall not be required to pay any regi~ration fees..
~ Yes ~o: Are You rePresentin~ a not-for-profit corporation or entiW without special comDensation
or reimbu~ment..
c~ i~o
V. SIGNATURE UNDER OATH:
ON OCTOBER Is~ 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 MIAM! BEACH FOR THE PRECEDING C~[~ENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDTTURES./~ ~O~/NS~.~'ION DUR.ING THE
REPORTING PERIOD..
S~gnature of Lol~byist/
I do solemnly swear that all of the/~eg~;:~
familiar with the provisions co~e~)~
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
/are true and correct and that I have read or am
the Miami Beach City Code and all reporting
PI~CZPAL IDENTIFICATION:
VII.
Produced ID
Form of Identification
/ersonally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
Produced ID
Form of Identification
~% Miche,,e D Koh,er
known
(Principal)
· _.~ · My Comm,saon DD148455
[i~ersonally ~'~;~oe°' Exp,res October 28 2006
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This t_L_~day of
Signature of Public Notary - State o oriOa
Notarization of Lobbyist's signature
/. FOR CLERK'S USE ONLY ~ ~/~-/~.
Annual Registration fee: [ I/]~es [ ] No Amount Paid~/~4~'''~O MCR # n~'/~c./'/
Lobbyist Registration Form received and verified by: /'I' ~ -
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.do~ / ~i~.--~
State of Florida, County of Miami-Dade
SThV~°s rln~SaUyb oSCfr~ ?~0.~ ?~ /_
Signature-of Public Notary - Stat~oYFIo~ida '~ '
Notarization of Principal's signature
Revised 12/08/04