Ilona-Anne Wiss/Vera Mender~. =~~_
City of Miami Beach Office of the City Clerk 2008 APR -4 AM I1 ~ 42
1700 Convention Center Drive, Miami Beach, FL 33139
CITY CLE~~'S OFF iCE:
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 activ'ties. 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:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip 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:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail) ~ ~ / ~ ~ ~~
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ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-482(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) Any'Filnancial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~~~~~ ~, 2~f f~. ~ ~ ~ ~Ci~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): Ali , ~ ' 6,/} j} ~ G~ C~
(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":
\ 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':
r Are you lobbying on a pending application for a Development Agreement with the City i
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.
reimbursement. .
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V. SIGNATURE UNDER OATH:
Signature of Principal/Client: ~i
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. IGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to d subscrib~jd- b~f re me
This ~ l6-a~i f''~lYv~~ .200
Public Notary -State of Florida
of Lobbyist's signature
IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dade ~0~~pA0 f~if ~?q
Sword ~ subscri ed bef a me ~ ~'~s•'~' ~~O
T 's lam. ~ a of , 2008 '~,,~' 1°~~,,Qo6
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Sig a re o P blic Notary -State of Florida ~~°~8~~89~
N'o rization of Principal's signature °~ll
~/ TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Pai O MCR Date Paid
Lobbyist Registration Form received and verified by:
Ft\CLER\LOBBYIST~lobbyist Registration Form 32706.doC Revised 03/27/2008
I do solemnly swear that all of the fore ing fact are true d correct and that I have read or am familiar with the
provisions contained in Section 2-4 the Mia each Cie ~d all reporting requirements.
Signature of Lobbyist: L
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
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LOBBYIST NAME: ~~ J
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: D te:
F:ICLERILt)EiBYiSTtLokrlayist registration Foam 3270~.doc