Christopher Middleton/Z. FelligE
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:
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
(Last) (First) (M.I)
(Number and Street) (State) (Zip Code)
FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) t (State)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
(Tip Code)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIF]C LOBBY ISSUE: l~lLl'"Te~l ~ L ~-~ ~'~
Issue to-be lobbied (Describe in detail): '
III,
Cl'rY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional RelaUonship
1V. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAT/ON (DISCLOSE WHETHER HOURI
FL.4T RATE OR OTHER~ ~
A) LOBBYIST DISCLOSURE: (Required) ~,~' ~/.-~[~_. ~')~I' _ ~(1~O
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSA-r~ON): (Required). -~- ~- ~ ~n! ~'~ ~;~,
The following information must be answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Tssues':
Yes J~No: Are you Iobbvinq on a present or pendina bid for .qoods, equipment or services, or on a
present or pendinq award for qoods, equipment or service?
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues':
DYes _~_No: Are you Iobbvinq on a pendin.q application for a Development A.qreement with the City or
application for chanqe of zoninq map desiqnation or chanqe to the City's Future Land Use
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..
Yes,~No: Are you representin.q a not-for-profit corporation or entity without special compensation
or reimbursement..
v. SIGNATURE UNDER OATH:
ON OCTOBER Isr OF EACH YEAR, EACH LOBBY]:ST SHALL SUBMI'T TO THE CI'TY CLERK A SZGNED
STATEMENT UNDER OATH, LI'STI'NG LOBBY]:NG EXPENDI'TURES, AS WELL AS COMPENSATI'ON
RECEZVED, TN THE CI'TY OF M'rAMT BEACH FOR THE PRECED]:NG CALENDAR YEAR. A STATEMENT
SHALL BE FTLED EVEN I'F THERE HAVE BEEN NO~'I'I~NDI'TURES OR COMPE_N:.~itI~N DURZNG THE
REPORTTNG PERi'OD. ~~...~~: ,/~/~
- "'--' Signatur~ ~f ~ler~-
! do solemnly swear.,that all of the foregoing facts are true and correct and that ! have read or am
familiar with the ' ' in Section e Miami Beach City Code and all reporting
requirements.
Sic
NT~FICAT/ON:
TD [] Produced ]:D
Form of Tdentification
Personally known (Lobbyist)
~)(Personally known
V'J:]:. S'rGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed~before me _
This_ ./.~ day o~?. ,~~., 20~_~
Signature of Public Notary - State 6f Florida
State of Florida, County of Miami-Dade
Sworn and subscribed before me --
This/~ d~,ay of~ 20__~
Signature of Public Notary - State of Flof-~Ja
Notarization of Lobbyist's signature//-' Notarization of Principal's signature
s~~[ ] FOR.CLERK'S. ~ ONLY
Annual Registration fee: [~ No A~,~)/2 MCR# ~..~: / 7~'DatePai~')~'--~
Lobbyist Registration Form received anv ' ' d verified
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.~1o'c/'~ Revised 12/08/04