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MIAMI BEACH
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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 "LO!lbbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: . (Last)
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BU NESS NAME AND ADDRESS umbe and Street)
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TELEPHONE NUMBER: FAX NUMBER:
EMAIL:
I.
BUSINESS NAME A D ADDRESS
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TELEPHONE 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)]
NA~OF\ CHIEF OFFICER, ~~RTNI'D nR BENEFI~RY: _ ^ _.' A ~ f'...\
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IDENTIFY ALL PERSONS HOLDING, DIk.7TL R INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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II.
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
~ FLAT RA TE OR OTHER).
A) LOBBYIST DISCLOSURE, (Reo.;'''') 1S ;, , tf e>vfl r11\ t$
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATI~N): (Required). f .
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 SHA L SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXP DITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE ECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXP NDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. _ II,,~
Signature of Lobbyis
I do solemnly swear that all of the foregoing f cts a true and correct and that I have read or am
familiar with the provisions contained in Sectio 2- 82 of the Miami Beach City Code and all reporting
requirements. p
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
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kroduced I ~11:i:/~ "t:( ~
h 1 H H(.~ I Form of Identification
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i~:'~. "(c:~COmI!llSSlQtl11l"erS6nJ3.IIY known (Lobbyist)
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"{'>6H-:'~~"" WV{~~\ROS~Al'URE AND STAMP OF NOTARY:
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e of otary S te of Florida
rization of Lobbyist's signature
FOR CLE
Annual Registration fee: [ Yes [ ] No Amount Pai
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc
PRINC AL IDE CA ON:
)@oducedI(SJ~ Jj~cB?~T(
l Form of Identification
o Personally known (Principal)
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..<'?'N.PY';", C ar es H. Holzer
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State of Florida Coun of ~fa'~j:-ba~~t Expires: AU:~, 26, 2~J8
Sworn and 'cri ed b ore 'ri1e~\;;;\'" WWWAARO'inOTARY,corr
This day 2~
Signa 0 IC Notary - State of Florida
rization of Principal's signature
Revised 12/08/04