Christopher Adams/Z. Fellig 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 prindpal 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:
(Last) (First) (M.I)
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
(Number and Street) (City) ~ (State_) I (Zip Code)
FAX NUMBER: EMAIL:
I. LOBBYZST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
L, o L, Lp t~,~T~Lz
BUSINESS NAME AND ADDRESS
TELEPHONE NUMBER:
· (Number and Street) (City)- ' i (state) (ZiplCode)
FAX NUMBER: (Optional)
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:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
ZI'. SPECIFTC LOBBY ZSSUE:
Issue to be lobbied (De~ribe in detail):
III, C~ AGENCIES/IND~DUALS
A) Full Name of Individual/TiUe
B) Any Financial, Familial or Professional RelaUonship
1¥. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY~
FL4 T R.4 TE OR OTHER.):.
A) LOBBYIST DISCLOSURE: (Required} ~. [.,~'~' ~'~'~,, ~ ~'l~'~0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSA-I'~ON): (Required). ~-"~::~'-J-' R/~Tt~ ';~ ~'"~) ") ~, ~
The following information must be answered:
l)
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
[] Yes ~io: Are you lobbying on a present or pending bid for goodsf equipment or servicesf or on a
present or pending 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":
[]Yes ?'~o: Are you lobbying on a pending application for a Development Agreement with the City or
application for chanqe of zoning map designation 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 representing a not-for-profit corporation or entity without special compensation
or reimbursement..
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: i~ ~
Signature /Client -
ENTZFZCATZON: PRINCIPAL ZDEN1/FICA1/ON:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYIST SHALL SUBMTI' TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN I'F THERE HAVE BEEN NO E~rPrr~NDTI'URES OR COMPENI~T,~ON DUI~NG THE
REPORTING PER]:OD. '
/
T do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am
familiar with the provisions coob--sined in Section 2-482 Qf LJ~e Miami Beach City Code and all reporting
requirements,
/
Form of Tdentification
rsonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, Countypf Miami-Dade
Sworn/~ and subscril~_ ~efore me
This/_.~P day of~.~c~/, 20~__~,
Signature of Public Notary - Stat~ of Florida
Notarization of Lobbyist's signature
[] Produced ID
Fo!
Personally known
State of Florida, County of Miami-Dade
Sworn ,a,~d subscr!b~tl before me
This I1., day of,.:~/./,~c~f.,~r,~, 20j2_~
Signature of Public Notary - State of Florida~/
Notarization of Principal's signature
\
~ FOR_CLERK'S USE ONLY #.~_~(~ /
Annual Registration fee: [ ~ [ ] NO Amou~_~aid..J'/~'/)'~ NCR
Lobbyist Registration Form received and verified by:~:jLr:T-/~ ' - / ,/
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 0~doc ~/) Revised 12/08/04