Laura Quinlan/The Rhythm Foundation
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MIAMI BEACH
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.
Q \)IN~AN [,l1v(\A
NAME OF LOeYIlZ H ~ r~ast) f D \) N D frt Lo Nrst) l tV 0
BUSIN SS NAME AND ADD SS (Number and Street) (City) 1
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TELEPHONE NUMBER: FAX NUMBER:
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\ ~eo..G~ L- 33131..:{
(Zip Code)
EMAIL:
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NAME OF PRINCIPAL! LIENT:
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BUSINESS NAME AND ADDRESS
(Number and Street)
(City)
(State)
(Zip Code)
TELEPHONE NUMBER:
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
· NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. c ~}CIfv L~YrSSUE: Iyr fA>
Issue to be lobbied (Describe in detail):
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DI. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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A) LOBBYIST DISCLOSURE: (Required)
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER):
V1 I (."
The following information must be answered:
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
DYes
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
7>tate Development Issues":
DYeS~o: Are vou lobbvinq on a pendinq application for a Development Aqreement with the City or
aoolication for chanqe of zonina map desiqnation or chanqe to the City's Future Land Use
Map?
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 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING E N DITU RES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE P ECED C NO YEA A TEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO, EX E DIT E R 0 NSA N G THE
REPORTING PERIOD.
I do solemnly swear that all of the fore in facts are true and correct and that I have read or am
familiar with the provisio co i i ~iQ. -482 of the Miami Beach City Code and all reporting
requirements. '/
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
rvProduced ID p,~~ L~ c
Fonm of Identification
o Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Signature of P IC of Florida
Notarizatio of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~uced ID b 1'V-.~c~ ;2~~-e...
Form of Identification
[J Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed b
This .2 l't1Iay, 0
,-
~.~.~ '1 KERRY HERNANOEZ ! ~
· . '. ~ MY COMMISSION # DO 626373 It
EXPIRES: May 3, 2011 ::;
erwrI\ers i ~
ta ~
rincipal's signature
ofV- ~ FOR CLE~ ONLY
Annual ~ glstration fee: [ ] Yes"[ l'No Amount Paid~
Lobbyist Registration Form received and verified by: (" .
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Date paid~
Revised 12/08/04