Laurence Destephen/Andrew Destephen/Monumental Worldm 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 LOBBYIST:
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(First)
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(City) (State)
(M.I)
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(Zip ode)
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TELEPHONE NUMBER: FAX NUMBER:
I. LOBBYIST RETAINED BY:
OF
BUSINESS NAME AND ADDRESS
and Street) (City)
ST rl: ~ `.
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:
. CofM
II. SPECIFIC LOBBY ISSUE:
1/C Gg~~T Ne NvMcW T1~L Fxt.4 ~ ~j~'
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
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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 OTHER]
A) LOBBYIST DISCLOSURE: (Required) _ l~
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 By Lobbyists
On Procurement Issues":
^ Yes 6~ No: Are you lobbying on a present or pending bid for goods equipment 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 Lobbyists On Real
Estate Development Issues":
x
QYes M NO: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map des~gnat~on or change to the City'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..
or reimbursement. ,
ON OCTOBER ~~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECENED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN'IF'THERE HAVE BL'EN NO EXPENDITURES OR C~MPEf~grTlO1V' DURING THE
REPORTING PERIOD. ~I --.~~
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of the
familiar with the provisions contains
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
facts are true and ~brrect and that I have read or am
vr2-482 of the Miami Beach City Code and all reporting
VI. ..LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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Produced ID ' . j/ ~
/~x~ ~ j~2~~1~~~ '- ~ oduced ID
Form of Identification Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATUR "'~"°'°"°"
~1~ Py~':= MY COMMISSION # DD 626373
State of Florida, Coun --Dac~(pIRES:May3,2011
Sworn to and subscri cf'p, ~na~arnmrio~yvubi~cundenv~cers
This ~i day of - ,
r
Sig ature of ublic Notary -- ida
Notarization of Lobbyist's signature
FOR CLERK'S U ®NLY
Annual Registration fee: [ -'Yes [ ] No Amount Paid L5 MCR # ~~Date Paid / ~ ~ ~
Lobbyist Registration Form received and verified by: ~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04
~7 Personally known
MY COMMISSION #
State of Florida, Co ~ •c~1A~'am6~ed~;;
Sworn an~subscribe e
This ~ay of ,~~~, 20~
Signature of Pubs fdotary = ~tate~f kl~
Notarization of Principal's signature