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MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA nON 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.
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BUSINESS NAME AND ADDRESS (Number and Street)
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TELEPHONE NUMBER: FAX NUMBER:
EMAIL:
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Zip Code) (
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I.
LOBBYIST RETAlNED 3-
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NAME OF PRINCIPAL/CLWNT:
BUSINESS NAME D ADDRESS
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TELE HO E NUMBER: -.;
(Number and Street)
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FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME F CHIEF OFFICER, ~RT E~ OR BENE~ICIAR;: fJ ~ .
IDENTIFY ALL PERS S OLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RA TE OR OTHER).
A) LOBBYIST DISCLOSURE: (Required) t1/1 / 0\
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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The following information must be answered:
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1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes
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..
DYes
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT 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 PRECEDI CAL DAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITU R OMPENSATION DURING THE
REPORTING PERIOD. 1,JJ
I do solemnly swear that all of the foregoin
familiar with the provisions contained in e i
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
o Produced ID CPr tvt.~ ~I;o
,"';:;'ylp~"', Charles H. Po 1721 Form of Identification
If'~''~'''~~~ Commission:# 0~1=:ldi
!.;,: :~:~Q .os' Personally)<nQwn (Lobbyist)
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"7,l,fU;~~"'VHf;li,l\.'SiGNAtURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn ,to\anp subscrib d before me
This~dayof ..,20~
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
.~oduced ID @o~ L..-"2-r-
( Form of Identification ~
tur IC Notary State of Florida
Ization of Principal's signature
Annual Registration fee: [~ ] No Amou t P .
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.d c
Revised 12/08/04