Torben Riise/Culture in the City, Inc
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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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NAME OF lOBBYIST: )
Execu.7eay}-)/ )nc,
BUSINESS NAME AND ADDRESS
;3 05"- 'r '1- J. - 'f~- 9 S-
TELEPHONE NUMBER:
(Last)
to 12/3 EN
(First)
(M .I)
FAX NUMBER:
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(City) I' (State) r' (Zip Code)
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All:
/3 fJ(;() J"VV
(Number and Street)
I. LOBBYIST RETAINED BY:
L u (ItA n? /n fA e
NAME OF PRINCIPAL/CUENT:
C'!y... /nc.
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BUSINESS NAME AND ADDRESS
13t, 5- - 7'ya - 9 5-$'~-
TELEPHONE NUMBER:
Ave i--1 I...j e'
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(Number and Street)
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(City)
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FAX NUMBER: (Optional)
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~J ~ r I!J (1,1... c1 C'L
or h (' n /!':u;:C-
· IDENTIFY All PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
I<~f:e,.- /Jof{det J,,'n&t/Aelh pore ~r6rn /(//5 e.
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II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied ( detail):
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III. CITY AGENCIES/INDMDUALS 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 HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On P curement Issues":
2) lurs - ant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Es te Development Issues":
DYes No: Are YOU lobbYinG on a DendinG aDDlication for a DeyeloDment AGreement with the City or
aDDlication for chanGe of zoninG maD desiGnation or chanGe 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..
)tYes 0 No: Are YOU reDresentinG a not-for-Drofit corDoration or entity without sDecial comDensation
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 COMPENSATION DURING THE
REpORnNG PERIOD. . ~
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Signature Lobbyist
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 contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
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Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Produced ID
Form of Identification
Produced ID
~ Personally known (Lobbyist)
~ Personally know
VII. SIGNATURE AND STAMP OF NOTARY:
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Sig ture of Public Notary - State of Florida
N tarization of Lobbyist's signature
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Annual Registration fee: [ ] Yes [ ] No A _ t i
Lo~byist Re~_istration Form received and verified by: ,'"
Date Paid & 27--
AFFIDAVIT
State of:
F/c>ridQ
lh/tunF -!JAde
County of:
I, 'r;; r /; -t' r/ R //5 L , being first duly sworn, say that I am the
- (NAME) /' . , 't {" I J
/ r e p... .r are r of cuI fur e i n {, e J "Ie' "1 (. .
(TREASURER or CHIEF FISCAL OFFICER, SOLICITOR OR CONSULTANT) (NAME of ORGANIZATION 0 COMPANY)
and further state that:
1. completed the Registration Statement;
(NAME OF PERSON COMPLETING REGISTRATION IF DIFFERENT FROM ABOVE)
2. The Registration Statement is made for the purpose of complying with the provisions of Chapter 496, Florida
Solicitation of Contributions Act;
Statutes,
3. I have read the Registration Statement and know the contents thereof.
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(S URE)
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The foregoing instrument was acknowledged before me thl..f7' day of J---GV \{}'-fl' '0 ' ~ r
by -JO t<. &/1./ ;0 I j e, , ~ me or who has produced
GLENDA LAVIN
MY COMMISSION # DO 589663
EXPIRES: Seplember7, 2010
Bonded Thru Notary Public UndelWritelS
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(NQ1 ARY PUBLIC NAME, PLEASE PRINT)
SEAUST AMP
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MY COMMISSION EXPIRES: 7 . ,7U / [,
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