David Keefe/Atlantic BroadbandMIAMIBE ACH
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
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 engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (l~st) (First)
BUSINESS NAME AND ADDRESS (Number and Street) (City)
TELEPI~ONE NUMBER: - - - FAX NUMBER:
(M.I)
(State) (Zip Code)
EMAIL:
" tt"" ""' "" ":
NAME OF P~NCIPA~C~ENT:
~S.!~SFqE 5D ~A~RE~ (Numberan?;tr~e5 ~
~LEPHONE 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 BENEF[CLARY:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 50/0 OR MORE OWNERSHIP INTEREST IN SUCH
II. SPECIFIC LOBBY IS~J.E:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIE$/IND/V~DUALS TO BE LOBBIED:
~l,~ldl ~e of Individual/Title
:' ~.i~
B) Any Financial, Familial or Professional Relationship
DZSCLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATZON (DISCLOSE WHETHER HOURZ Y~
FLA T RA TE OR OTHER~
The following information must be answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
/~l~es~ [] No: Are you lobbying, on a present or pendin.q, bid for hoods,, equipment or service%__ or on -
present or pending award for .qoods, eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
[]YeseS'o: Are you Iobbyin~ on a ~endinq application for a Development Aqreement with the City o,
/~ aoolication for chanqe of zoninq map desiqnation or change to the City's Future Land Us~.
Map?
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 2-48! 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/~?o: Are you representing a not-for-profit corporation or entity without special compensatio,,
or reimbursement..
V. SZGNATURE UNDER OATH:
ON OCTOBER 1~r OF EACH YEAR~ EACH LOBBY[ST SHALL SUBI~IZT TO THE CTTY CLERK A SZGNED
STATEMENT UNDER OATH, LTSTZNG LOBBYZNG EXPENDZTURES~ AS WELL AS COIqPENSATTON
RECEZVED~ ZN THE CTrY OF IqTAIq! BEACH FOR THE PRECEDZNG CALENDAR YEAR. A STATEMENT
SHALL BE FZLED EVEN ZF THERE HAVE BEEN NO EXPENDZTURES OR COIqPENSATZON DURZNG THE
REPORT1'NG PERZOD.
Signature ~/~r~yist
! cio 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-~82/o~he Miami Beach City Code and all reporting
Signature of Lobbyist:
Signature of Principal/Client:
VI:. LOBBYZST ZDENT]:FZCA'rZON: DENTZFZCATZON:
Form of Identification
Form of Identification
[] Personally known (Lobbyist) [] Personally known (Principal)
V/Z. SZGNATURE AND STAMP OF NOTARY: ........... ,.,,,o,.o-~
! LAURA
S~te of Florida, Coun~ of Miami-Dade ......... ,~ Sta~ ~ ~,_.~. ........ · ..............
. s bscr,b d bef~me . U ~---~Sworn ub~ri db ~ ~
t =~ ~'~ - '' · .....................
S~ nature of Pubhc Nota
g ~ - ~~:~: .... S~gnature of Public Nota~ - State of Florida
No~rization of Lobbyist's signature No~rization of Principal's signature
. ~ FQ~LER~ U~ONLY~ / ~/I12~08/
~nual R~i~ation fee: [ ( ~ ]No A~aid ~ .~ MCR ~ Date Paid
Lobbyi~ Regi~ra~°n Form ~eiv~ and verified by~
F:~CLER~$ALL~NA~A-N~LobbyisL~LOBBY~ ~RN ~.~¢~ Re~i~d