Terry DeCarlo/Community Aids Resource dba Core Resourcesm MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
NAME OF LOBBYIST: (Last) (First)
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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.
BUSINESS NAME AND ADDRESS ~ (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT'
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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:
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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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Issue to
III.
CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
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B) Any Financial, Familial or Professional Relationship
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II. SPECIFIC LOBBY ISSUE:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ( J
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Erocurement Issues":
Drgsent or bending award for goods, eguiument or service?
2) aursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
n, v~,~wNo• Are you lobbvina on a Dendina aDDlication for a DeYeloument Agreement with the City or
aDDlication for change of zoning maD designation or chance to the Citv's Future Land Use
MaD?
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..
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 EXPENDIT COMPENSATION DURING THE
REPORTING PERIOD. ~ /~ l1 n
ignat6rcrof Lobbyist
I do solemnly swear that all of the
familiar with the provisions containe
requirements.
^ Produced ID
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Form of Identification
Personally known (Lobbyist)
ng facts are true and correct and that I have read or am
Lion 2-482 of tF)er'r(liami Beach City Code and all reporting
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed fo me
This ~ u day of , 20~
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ure of Public No - tate of Flor
Notarization of LobbvisY signature
PRINCIPAL IDENTIFICATION: ~'~
^ Produced ID
Form of Id t
~~
^~rsonally known (Principa
State of Florida, County of Mia ' Bade ~
Sworn and subscribe efo
This~~da f _L~/// 20 ~
Signature o Public Notary -State of= for
Notarization of Principal's signature
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Annual Registration fee: ( ]Yes No Am n Pa MCR # id
Lobbyist Registration Form received a d verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05 oc Revise 12/08/04