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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, resoiution, 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 defined in any
manner in this section, during the time period of the entire decision-making process on such action, ecision or recommendation
that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The t specifically includes the
principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exc ions. Please refer
to Ordinance 2004-3435. .
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NAME OF LOBBYIST: (Last) (First)
'/ZoSeN >wlTtter i t;V"'''' i>.l .
BUSINESS NAME AND ADDRESS (Number and Street) (City)
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(State)
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TELEPHONE NUMBER:
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FAX NUMBER:
EMAIL:
I. LOBBYIST RETAINED BY:
SOfA T It' ~ eo"'k ,., I-I-re I "Itr'-f I, t..L '-
NAME OF PRINCIPAl/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street)
?,C) g 7<.( 5700
TELEPHONE NUMBER:
^" lAM.
(City)
F\.. "'3 ~ , ~ 7
(State) (Zip Code)
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:
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· IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
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II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (DeSCribe in detal
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CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
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" A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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1S6~O cF A-oTil'- $ r,." eN r i\JC>
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RA TE OR OTHER)
A) LOBBYIST DISCLOSURE: (Required) JJ ztjO ec;>
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). j 1-5"l) . 0 ~
o Yes without s ecial com I ensation or
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· 3 ~ State of Florida, County of Miami-Dade
Sworn to and sUbscribCf bef?re me
"..I", This & n.J day of ~ ,200-:r
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\:~ .. .J,J Signature of Public Notary -= St e of Florida
"'~~.,,;..i\;;'~ Notarization of Lobbyist's signature
D Yes 'NO:
DYes clNo:
1)
Pursuant to Ordinance No. 2003-3393 AmendinG Miami Beach City Code Chaoter 2, Article VIr. Division 5
Thereof Entitled "Campaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaion Contributions Bv Lobbvists On Procurement Issues":
Are yOU lobbvina on a oresent or oendina bid for aoods, eauiDment or services, or on a oresent
or oendina award for aoods, eauiDment or service?
2)
Pursuant to Ordinance No. 2003-3395 AmendinG Miami Beach City Code Chaoter 2, Article VII Division 5
thereof Entitled "Campaion Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
CamoaiGn Contributions Bv Lobbyists On Real Estate Develooment Issues":
Are YOU lobbYina on a oendina aoolication for a DeveioDment Aareement with the City or
aODlication for chanae of zonina maD desianation or chanae to the City's Future land Use Map?
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 TH CED G CALENDAR YEAR. A STATEMENT
SHAll BE FILED EVEN IF THERE HAVE BEEN NO PENDITURE CO NSATION DURING THE
REPORTING PERIOD.
I do solemnly swear that all of the foregoing facts e e and correct and that I have read or am
familiar with the provision tained in Section 2-482 of the Miami Beach City Code and all reporting
requirements,
Signature of Lobbyist: /
VI.
LOBBYIST IDENTIFICATION:
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~;roduced ID fill. DL-
Form of Identification
PRINCIPAL IDENTIFICATION:
[]}'?:O-duced ID fLt b L-
Form of Identification
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o Personally known (lobbyist)
o Personally known (Principal)
SIGNATURE AND STAMP OF NOTARY:
, U8ff>N~R #2gq I rv Date Paid
LL\MARIA-M\LOBBYIST\LOBBYIST FORM 04
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Annual Registration fee: Yes [ ] No Amo t
Lobbyist Registration Form received and verified by:
Revised 02/10/04 . CL