Raymond Adrian/MB Hispanic Community Center~ 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 lobbyin ' 'ties. The term "Lobbyists" has specific exclusions. Please ref Ordinance 2004-3435.
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NAME OF LOBBYIST; ~ (Last) (First) v (M.I)
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BUSINESS NAME AND ADDRESS (Number and Stre t) (City) (State) (Zip Code)
TEL ONE NUMBER: FAX NUMBER: EMAIL: _`
I. LOBBYIST RETAIN BY:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip 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)]
• 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):
III. CITY AGENCIES/INDIVIDUALS 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 R.9TE OR OTHERS ' ~
A) LOBBYIST DISCLOSURE: (Re uired) 6 ~„~' v ~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required)..
The following information must be answered:
PRINCIPAL IDENTIFICATION:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
~ Yes o: Are ou lobb in on a resent or endin bid for oods a ui ment or services or on a
present or sending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes No: Are ou lobb in on a endin a lication for a Develo ment A reement with the Cit or
application for change of zoning map designation or change 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 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 ou re resentin a not-for- rofit cor oration or entit without s ecial com ensation
~, or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A S I GNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, SWELL AS COMPENSATION
RECEIVED, I N THE CITY OF MIAMI BEACH FOR THE PRECED I N C ~.ENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES 0 ~ COMPENSATION DURING THE
REPORTING PERIOD. , - ~~
Signature of Lobbyist
do solemnly swear that all of the regoing facts are true and correct and that I have read or am
familiar with the provisions contain d E in Section 2-482 of the Miami Beach City Code and all reporting
,.
requirements.
Signature of Lobbyist:
Signature of PrincipaUClient:
VI. LOBBYIST IDENTIFICATION:
~~~ Produced I D
~ o Form of Identification
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Personally known (Lobbyist)
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~ VII. SIGNATURE AND STAMP OF NOTARY:
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~' State of Florida, County of Miami-Dade
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~c~w Sworn to and subscribe befor me
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State of Florida, County of Mi i ~ gia a Fonseca
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Signature o~Public Notary -State of Florida
Notarization of Principal's signature
FOR CLERK'S U O.~VLY
Annual Registration fee: ]Yes [ ] No Amount id MCR # ~- ~- Date Paid
Lobbyist Registration Form received and verified by:
F:\CLERI$ALL(MARIA-M1LobbyistlLOBBYIST fORM 05, Revised 12/08/04