Mary Schultz/Fantasy Theatre Factory
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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
CIly 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 tenn specifically includes the principal as well as any employee engaged
in lobbying activities. The term .1.0..,..... ......1fIc DC........ PIeMe refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (M.!)
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TELEPHONE NUMBER:
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FAX NUMBER: EMAIL:
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CUE :
\= 11 (' ',\-r) ;~ j
BUSINESS NAME AND ADDRESS
(Number and Street)
(Oty)
(State)
(Zip Code)
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TELEPHONE NUMBER:
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FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this ..ctIon If principal is a Corporation, Partnership or Trust [SectIon 2-482 (c)]
.
NAME OF CHIEF OffiCER, PARTNER, OR BENEACIARY: ~'c..\. .-i~ \ \~,'-
.
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIREcn. Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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U, SPECIFIC LOBBY ISSUE:
UL CITY AGENCIES/INDMOUALS TO BE LOBBIED:
A) Full Name of Individual/TItle
B) Any Financial, Familial or Profellllonal Relationship
IV. DISClOSURE OF TERMS AND AMOUNlS Of LOBBYIST COMPENSATION (DISO.OSE WHEllfER HOURL Y,
Fl.A T RA~ OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) I' 0 l-. 0
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B) PRINCIPALS 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 Conbibutions By Lobbyists
On Procurement Issues":
o Yes ~: Are YOU lobbYinG on a Dresent or D8I'Idlna bid for Goods. eauiDment or services. or on a
IH'8Hnt or DendlnG awarel for aoocIs. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Conbibutions By Lobbyists On Real
Estate Development Issues":
DYes e-14~: Are YOU IobbYina on a DIlnclina aDDiication for a D8v8IoDment AGreement with the City or
aDDlication for chanGe of zoninG maD deslanation or chanae to the City's Future Land Use
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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-proflt
cOll>Oration 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 derk as required by this
~_.section but., shall not be required to pay any registration fees,.
~. 0 No: A~ YOU reoresentinG a not-for-DrOflt corooration or entitY without SD8Clal comDellSation
or reimbursement. .
V. SIGNATURE UNDER OA11t:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTING LOBBYING EXPENDITURES, AS WELL AS COMPENSAnON
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 COMPENSAnON DURING THE
REPORTING PERIOD. i ,1" ,7 I ,1
/ ? L-J;iL/;
, - signa~e" of 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 Mia Beach City Code and II reporting
requirements. ) /
Signature of lobbyist: '
Signature of Principal/Client:
VI, LOBBYIST IDENTIfICATION: PRINCIPAL IDENTIFICAnON:
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Form of Identification Form of Identification
U Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
U Personally known (Principal)
I.ldle t. CriltDlNll
f* CommiMIon DD27513Signature of
ExplrM December 11. 2OONotarizati
Date Paid
, / OR CLERK'S USE ONLY
Annual Registration fee: [ ] Yes [ V] No Amount Pa" MCR #
Lobbyist Registration Form received and verified by:
F:\CLER\$AlL \MARIA-M\Lobbyist\LOBBYIST fORM OS.d
Revised 12/08/04