Maritza Guimet/Florida Media FFIm 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) ~~'~~~ ~ I
TELEPHONE NUMBER:
City of Miami Beach Office of the City Glerk
1700 Convention Center Drive, Miami Beach, FL 33139
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I. LOBBYIST RETAINED BY:
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FAX MBER:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code) ~ ~~~
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: •~~~~ ~- ~~ l L ~~ `~ `~ ~ ~-. ~' ~ ~ t
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IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATTION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOB~ISSUE:
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Issue to be lobbied (Describe in detail): ti.
III. CITY AGENCIESjINDNIDUALS TO BE LOBBIED:
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A) Full Name of Individual/Ttle B) Any Financial, Familial or Professional Relationship
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N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION {DISCLOSE WHETHER HDURIY
FLAT RATE 4R OTHERS
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions B Lobb fists
On Procurement Issues : y y
Y No: Are ou lobb in on a resent or endin bid for oods a ui ment or services or on a
present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobb fists On Real
Estate Development Issues": y
Yes o: Are ou lobb in on a endin a lication for a Develo ment A reement with the Ci or
application for change of zoning map designation or change to the Citv'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- rofit
corporation or entity without special compensation or reimbursement for the a earance whether dir p
indirect, to express support of or opposition to any item shall re inter with pp ect, or
9 the clerk as required by this
section but, shall not be required to pay any registration fees..
es ~ No: Are ou re resentin a not-for- rofit cor oration or enti without s ecial com en
sacton
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 PRE~EDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDTTU, S 4R COMPENSATION DURING THE
REPORTING PERIOD. ,, ., ..~ ,,,~
Signature of Lobbyist
I do solemnly swear that all f the foregoing facts are true and correct and that I have read or am
familiar with the provisions co tai ed 'n Section 2-482 of the Miami Beach City Code and all re ortin
requirements. p g
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Signature of Cobb fist: ~,
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Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
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~oduced ID ~ ~~ ~ ~ ~ ;~
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Form of dentification
D Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY;
PRINCIPAL IDENTIFICATION:
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roduced ID ~~-~c.~ ~~~-~'.-.~.
Form of Identification
D Personally known (Principal)
State of Florida, County of Miami- tate of Florida, County of
Sworn to an subscribe ;
This ~~ da -o ~~~ ~ ,,, ~ ,,
~ AYHERNANDQ
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20 OMMISSION # DD 626373
worn and subscribed befo
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: MY COMMISSION # DD 6
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~• a;= EXPIRES; May 3,2411
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day of 26373
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ublic o ary - o on a Signature of P lic Nota tate Florida
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Notarization of lobbyist`s signature Notarization of Principal 's sign
FOR CLERK' ,SE ONLY ~ ~.,.
Annual Registration fee: [ /J Yes [ ] No Amount Pai ; ~ MCR # Date Paid g
Lobbyist Registration Form received and verified by:
F:~CLER~$ALL~MARIA-M\Lobbyist~LOBBYIST fORM 05.doc ~ Revised 12/08/04