Samuel Poole III/AEG Live, LLC
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MIAMIBEACH
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.
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(Last) (First) (M.!)
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(City) (State) ip Code)
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FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
!lEG Lt've. L.LC
NAME OF PRINCIPAl!CUCNT:
)1Ic1 & I fe. 5DI Los.
(City)
3~3 -93D"' S'11;;J
FAX NUMBER: (Optional)
Cf4 90D:30
(Zip Code)
3 J.. 3 --930- 5 711
TELEPHONE NUMBER:
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF .fHIEF OFFICER, PARTNER, OR BENEFICIARY: Ra.r"Idr pJ."LL,f S, R-e>S; d~", t
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPO~TI?N,PARTNERSHIPORTRUST: At~t.'''~~lc- b C.NI{(/)\Ic!) OJ "V\5c..lrto.\'1- i"'1C,-tc.I..,-"t"t
tL<.. lJh I <-'^ ll>pOIMtI\ &1.:) 00"'0 Co... t,..c Hc:c oS... -n,c: A...~til u.1'1- L.,.... ,)0"'" lU 11\ d... 'J' 1.0 CO, .
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II. SPECIFIC LOBBY ISSUE: IY\ a t"\lA j l2..Y\'\ e.f'. t- a,j f'< ~lY)~-'"\ T ~ r Jet c:... ki e.. 6.-1 e ({Scy<l\{:<4,.h, r-
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE lOBBIED:
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A) Full Name of Individual/Title
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B) Any Financial, Familial or Professional RelatiO~iP "
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLATRATEOROTHER): ~ . / . ' '.-4
A) LOBBYIST DISCLOSURE: (ReQUired)3g0 h"Ou I un}; I /z/g.I/rx" 4(o/~{' 1tJe(fC{fb:-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSA~ION): (ReQUiredr38D/hr l)1l1;\ /2./1 l/Ob... -fLJlfJ /I,r th€r(~~
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 D No: Are you lobbvina on a present or oendina bid for aoods. eauioment or services. or on a
/ oresent or oendina award for aoods, eauioment 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 lobbvina on a oendina aoolication for a Develooment Aareement with the City or
aDolication for chanae of zonina mao desianation or chanae to the City's Future Land Use
MaD?
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..
D Yes ~ No: Are yOU reoresentina a not-for-orofit corooration or entity without soecial comoensation
or reimbursement.
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 PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR CO ENSATION DURING THE
REPORTING PERIOD.
, iT(
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contai d in Section 2-48 of the Miami Beach City Code and all reporting
requirements. ~
Signature of Lobbyist:
VI.
PRINCIPAL IDEN'l{CA~:
~duced ID il/ ru'a./JL!-1f7b:33t3
Form of Identification
IJ Produced ID
Form of Identification
J5-. Personally known (Lobbyist)
o Personally known (Principal)
SIGNATURE AND STAMP Of NOTARY:
~n::wMcA
State of Florida, County of P1ial'l'li Daek
Sworn to and subscribe before me (
This day of C'J r: 202-b
VII.
Notary Public State of Flonda
Kimberly I Wagner
My CommiSSIOn OD589224
Expires 08/27/2010
Signature of Pub IC Notary - State of Florida
Notarization of Lobbyist's signature
. /' FOR CLERK'S U~9NL Y
Aoo",.' R'9''''''oo "" [V"""[ ] No Am,""~P --11CR.
LobbYist Registration Form received and verified bY:. fM
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM Os.doc /