Mathew Gorson/The Related GrpMIAMIBEACH
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, dedsion 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 dty commission, or a city 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.
NAME OF LOBBYIST: (Last) (First)
BUSINESS NAME AND ADDRESS (Number and Street) (City)
TElEPhONE I~UMBER: FAX NuIvrBEIS,: -
(M.I)
Fz-
(State) (Zip Code)
kJ EMAIL:
I. LOBBYIST RETA/NED BY:
NAME OF PRINCIPAL/CLIENT:
B.gSINESS NAME AND ADDRESS (Number a d~Btreet) (City)
T'ELEPHONI~ 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 BENEFICIARY: ~/~0'(~ ?d~E~
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORA'I'~ON, PARTNERSHIP OR TRUST: ~..~~ ~
SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
ITl. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Titie
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AHOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURI
FI.A T RA TE OR OILIER.):.
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE COF LOBBYIST COMPENSATION): (Required).,I.~ ~v['A
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":
,Il
Yes ~o: Are YOU Iobbyina on a present or pendinq bid for aoods, eauioment or services, or on a
present or Dendina award for aoods, eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
I~Y~$ ~i~'0: Are YOU Iobbyinq on a pendinq aDDlicati0n for a Devql0pment Aareement with the City or
application for chanoe of zonina mad desianation or chanae to the City's Future Land Use
Moo?
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..
O Y~$ I~0: Ar~ yq~ reDresentina a not-for-profit corporation or entitv without soecial compensation
qr reimbursement..
V. SZGNATURE UNDER OATH:
ON OCTOBER Is'r OF EACH YEAR, EACH LOBBY!ST SHALL SUBMI'r TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LIST!NG LOBBY]:NG EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, TN THE CITY OF MIAM! BEACH FOR THE PRECED!NG CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN !F THERE HAVE BEEN NO EXPEND!TURES OR COMPENSAT!ON DUPING THE
REPORTZNG PER!OD. ~~~
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in ' of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
V/. LOBBY!ST IDENT~F~CAI'J:O PI~TNC]PAL TDENT~I~CAT~ON:
[] Produced ID [] Produced ID
Form of Identification Form of Tdentification
/Personally known (Lobbyist) '~~nally known (Principal)
VII, SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom ]~b~o_d subscrib :1 before m
--- _;
Si~~at~J~f ~ ~,, I~ ~ # D0 17874~
Notarization ~ ....... ~ I1:~. :~
State of Florida, County of
Sworn and sub~ ;rjbed befo~~J~SCo.
this ~ ~-~;r." -
Signat~! c f~P~b~~~''-'''-''
Notarization of Principal's signature
/ FOR CLEI~K'S USE
Annual Registration fee: [ ~v/] Yes [ ] No Amount Paid'~_~---~
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBY[ST fORM 06~)~ ....
MCR #*~)l-~~Date Paid
/
Revised 12/08/04