Michael F. Bath/Nat'l Gay & Lesbian Task Force Foundationm 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.
NAME OF LOBBY ST: (Last) (First) (M.I)
BUSINESS NAME D ADDRESS (Number and Street) (City)
TELEPHONE NUMBER: FAX NUMBER:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIE
:~T~ ~3~37
~~~~
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp 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: ~ ~~ ~~ ~ ~~~1 ~x,~~` ~ ~Y~`
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: N ~ V~
II. SPECIFIC LOBBY ISSUE: `
Issue to be lobbied ( ribe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf `` ` ((~~'~ (~
A) LOBBYIST DISCLOSURE: (Required) r-~ Ca`c' ~S ~.~- ~ ~~ `~~ 9\~!`c .~c...,bC~ c7r (~'~~~'~~Q`-`
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ cL ~-~ "' {-
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":
11 Yes C~3'No: Are you lobbvina on a Dresent or oendina bid for goods, eauiDment or services, or on a
present or oendina award for goods, eguinment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled 'Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes ^riVo• Are you lobbvina on a oendina aonlication for a Development Agreement with the City or
aDnlication for change of zoning map designation or chance to the City' Future Land Use
Ma°?
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 anot-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..
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ 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 f~MPENSATION DURING THE
REPORTING PERIOD. ~ ~ // // ~ /I /I
Signature of Lobbyis
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 Se n 2-482 of the ami each City Code and all reporting
requirements. t-
Signature of Lobbyist:
Signature of Principal/Client:
VI. /LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
tr' Produced ID ~~L~ ~3ou - ~J~~S'ioS- D~~~ ~ Produced ID Fit,#133 LSD-S I~/J - o/'}-O
Form of Identification Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF
,, „~~,,,. UWAN BEAUCHAMP
State of Florida, County of :~, My COMMISSION i« DD 53a
Sworn to and subscribed . = EXPIRES: April 29, 2010
This ~.~_day of ,,, ~ Qe`~ne~emr~~rU1d°""'
Signature of PubN"c Notary -State of Flol
Notarization of Lobbyists signature
^ Personally known (P~'i'r`i~~ UU.IAN BE!-~UCHAMP
•: ~~~ MISSION N DD 530416
:,y.r~ EXPIRES: April 29, 2010
'•.',',~, ~ ~~` Bonded Tixu Notary PubNo Underndlera
BF,.
S e of Florida, County» ~ - - a e
S rn and subscribed afore me
~~day of 20 0'~-
Signatur o Public Notary - fate of Florida
Notarization of Principal's signature
FOR CLE ONLY U~
Annual Registration fee: [ ]Yes [ ] No Amou Paid MCR # aid U
Lobbyist Registration Form received and verified by: ~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04