Yvonne McCormack/Women International Film Festival
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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 I bbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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(First) (M.I) _
flo ~E" /9'1 '5/; #/01 Miami 33177
(City) (State) , ICZiP Code)
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EMAIL: ---1
AME OF LOBBYIST: (Last) .
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BUSINESS NAME AND ADDRESS (Number and Street)
3D:S- b53 970D
TELEPHONE NUMBER:
FAX NUMBER:
I. LOBBYIST RETAINED BY: ~
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BUSINESS NAME AND ADDRESS
3D5~53 ~7ro
(Number and Street)
lq OBI\JE 19q~~~
(City) (State) (Zip Code) 'D I -
~ VDYlIle: 0. W l FfVt) UIlE'. D( 6- 33 / 7~
FAX NUMBER: (Optional) . EMAIL: (Optional)
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TELEPHONE NUMBER:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)l
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECfLY OR INDlRECfLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of IndividuaJ/TItle
B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
--0--
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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":
D Yes ~ Are YOU lobbyinQ on a present or pendinQ bid for Qoods. equipment or services. or on a
present or pendinQ 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":
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..
v. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf 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 EXPENDITU ES OR PENSATION DURING THE
REPORTING PERIOD.
PRINCIP IDENTIFICATION:
,~ced ID I~ ._1u:-~
Form of Identification
I do solemnly swear that all of the foregoing facts ar true and correct and that I have read or am
familiar with the provisions contained in . of the Mia i Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. ~LOBBYIST IDENTIFICATION:
Produced ID l~1J"4~ .fl~
Form of Identification
D Personally known (Lobbyist)
(J Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
. . re meKERRY HERNANDEZ
.: ~ ~1'sBION # DO 626373
: ifPlRt's: May 3, 2011
r..r,I..' Thru Notary Public Underwrllera
2j 2j 01'
Revised 12/08/04