Terry DeCarlo/Wade Pattersonm MIAMIBEACH
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: (Last) (First) `- (M I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL.
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLttn i
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: FAX
EMAIL:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482
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. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
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III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf 1^
A) LOBBYIST DISCLOSURE: (Required) ~ l A~~ ~,^
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). . .u~a~'~
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":
^ Yes No: Are you lobbvina on a aresent or pending bid for aoods, equipment or services. or on a
present or Dendina award for aoods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Y~~ No: Are you lobbvina on a Dendina application for a Development Agreement with the City or
application for chanae of zoning map designation or chanae to the Citv's Future Land Use
Mao?
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..
~~Yes ^ No• Are you representing snot-for-profit corporation or entity without special compensation
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 EXPENDTTUF~ OR COMPENSATION DURING THE
REPORTING PERIOD. ( ~~ ~
obbyist
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 ~ a' din Section 2- 2 of the Miami Beach City Code and I reporting
requirements.
Signature of Lobbyist: •~"'~*~;
Signature of Principal/Client: ~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
~® Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to apd subscribed (before me °~
Thls~~ ( day of /,f~, 20~ ~f"~
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Signature of Public Notary - State of Florida ~ V
Notarization of Lobbyist's Signature "/~ --/"~
Annual Registration fee: [ ] Yesl[/ ] No Am
Lobbyist Registration Form received and verified by:
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PRINCIPAL IDENTIFICATION: o
S~
^ Produced ID •~~
Form of Identification 9y
~1-P~sonally known (Principal) '`°bi~~,
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State of Florida, County of Miami-Dade
Sworn and subscribed efore me '7 ~~
This ._[_d-ay~of !~_. «' 20 G- /
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Signature of Public Notary -State of Florida \ U
Notarization of i cipa s sign~ftur
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