Kevin Maguire/Atlantic BroadbndMiAMiBEACH
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, derision 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: (Last)
BUSINESS NAME AND ADDRESS (Number and Street)
30S---S;S--
TELEPHONE NUMBER: FAX NUMBER:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS ~ (Number and Street) (CiW) ' - '
NUNBER:
FAX NUMBER: (Optional)
(State) (Zip Code)
w EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or TrUst [Section 2-482 (c)]
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
SPECIFIC LOBBY ISSUE:
ssue to be IolJbied (l~scribe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
:' ":, i ' ' . . i' al/TiUe
B) Any Financial, Familial or Professional RelaUonship
~V. OZSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAT[ON (DISCLOSE WHETHER
A) LOBBY~ DISCLOSURE: (Required} ~ ~
(OF LOBBY]~ COHPENSA~ON): (Required). ~--~ ~_~)~
B)
P~NC]PAL'S
DISCLOSURE
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":
D Yes .E~o: Are you Iobbyinq on a present or pending bid for
qoods,
equipment
or
services,
or
on
present or pending award for qoods, equiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes ~o: Are you Iobbvinq on a oendinq application for a Development Agreement with the
City
ol
/
application for change 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 2-481 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 [~lfNo: Are you representinq a not-for-profit corporation or entity without special compensa[i°n
or reimbursement..
V. SIGNATURE UNDER OATH:
ON OCTOBER ::[ST OF EACH YEAR~ EACH LOBBYIST SHALL SUBMTr TO THE cTrY CLERK A SIGNED
STATEMENT UNDER OATH, LISTZNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEZVED, IN THE CTI'Y OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE F"ZLED EVEN IF THERE HAVE BEEN NO EXPEND~rrURES OR COMPENSATION DURING THE
REPORTING PERIOD.
~ -
· / 1 Signature of L'~ll~ist
! do solemnly swear that all of the foregoing facts/-are true and correct and that ! have read or am
familiar with the provisions co.ntain~d in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:/ ~--~ ~,~1/~ ~ ~/,~-
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
.~Produced ID ~~ ~roduced ID' ~'"'~ L ,..,'
Form of Identification Form of Identification
[] Personally known (Lobbyist) [] Personally known (Principal)
V1:I. SIGNATURE AND STAMP OF NOTARY: ~ --
State of Florida, County of Miami-Dade State of Florida Coun .~ j~j~,~:,,,.~,~;;,,, corem# 0o02~otll
Sworn o a~,qd subscribed before.~e ................... :--:: ~:: :::: -'or su ' ' ty of Mi~~
................ _'2- bscrib before ~.~
~ ,.,:... Corem .~ ; ' ....
~ignature of Public Notary - Sta~ ~...,~a F"'~aOa Nc~ry/~ssn .,:~i§nature~of ~Pu'~lic Notar~ -"~tate of Florida
Notar,zatlon of Lobb ist's si .~.., ..#.-,-.. ................ 1~ '
· ' Y' '~ "; 6tarization of Principal s signature
// FOR CLER~ US.~ONLY
Annual Registration fee: [I/]' Yes [ ] No Amo~lnJ:~Pa'~--~~L/~. MCR # Date Paid I1~i~, ~:~
Lobbyist Registration Form received and verified by: [ !/~__~ ./C)~cl -
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.d~c - I - I I
Revised ]2/08/04