Michael Larkin/1616 Drexel AveAMIBEACH
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 dty commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged
/o lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST:
BUSINESS NAME AND AD, pRESS
TE]_EPHONE NUMBER:
(Last) (First) (M.I)
(Number and Street) (City) (State) (Zip Code)
FAX NUMBER: EMAIL:
I. LOBBYIST RETATNED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City)
(State)
(Tip Code)
~ I:LEPHONE NUMBER:
FAX NUMBER: (Optional)
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:
Issue to be lobbied (Describe in detail):
CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/TiUe
B) Any Financial, Familial or Professional Relationship
DTSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURI
FI..,4 T RA TE OR OTHER,):.
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
Yes/~No: Are you Iobb¥inQ on a present or pendinq bid for goods, ecluiDment or services, or on -
D
present or pendinq award for qoods, eauir~ment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
13Yes/~t/No: Are you IobbyinQ on a pendina aoplication for a Development Agreement with the City
application for chanqe of zonin.q map desiqnation or chanqe to the City's Future Land
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 E~o: Are you representin.q a not-for-profit corporation or entiblf wiLliout special compen-~tlor
/ ~ or reimbursement.. --
V. SIGNATURE UNDER OATH:
ON OCTOBER Isr OF EACH YEAR, EACH LOBBY[ST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDI'rURES, AS WELL AS COMPENSATION
RECEZVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PER~OD.
! do solemnly swear that all of the foregoing facts are true and correct and that T have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist: /~J~ ~/,~/'~/'-~
Signature of Principal/Client: ~
LOBBYIST IDENTLFICATION:
[] Produced ~D
// Form of Identification
Ily known (Lobbyist)
PRTNCIPAL IDENTZFZCATZON:
/
~ Form of Identif~ation
[] Personally known (Principal)
SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ]~;~ day 9f/,-~-20
Notarization of~~s~i~~'~y :~, ~007 ~ ,
.... ~ FOR CLER~ I
Annual Registration fee: [ ~Yes [ ] No Amount Paid ~__ MCR ~~~
Lobbyist Registration Form received and verified by.: ~~~
F:~CLER~$ALL~MA~A-M~Lobbyist~LOBBYIST lORN ~-- -' ~
State of Florida, County of Miami-Dade
Sworn an(J.subscribed before me '
This / E~r"/~d
Signature of ~-'~,~s t~
Notar,zat,~~
usE-~NLY .---
Revised 12/08/04