Hiram A. Ruiz/Rob Schuler
m MIA,MIBEACH
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 seeN;s 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 aty 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 speafically includes the principal as well as any employee engaged in
lobbying activities. The term "Lobbyists" has specific exclusions. Plesse refer to Ordinance 2004435.
LOBBYIST: (Last) (First) (M.I)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY:
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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 pNncipal is a Corporation, Partnership or Trust [Section 2-482 (c)I
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:
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Issue to be lobbied (Describe in detail):
ul. CITY AGENCIESIIN171VIbUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERr
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A) LOBBYIST DISCLOSURE: (Required) ~~ I ~°~'
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). N (H'-
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":
o i n n r n' i n on
present or cending award for goods, eguioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Coritributions By Lobbyists On Reat
..E//st~~ate Development Issues":
oyes L~vo: Are you lobbying on a cending application for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
Mau?
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 snot-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 derk as required by this
. section but, shall not be inquired to pay any registration fees..
D'lfes ^ No: Are you representing goof-for-profit corporation or entity without special comcensation
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 A5 COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURE5 OR COMPENSATION DURING THE
REPORTING PERIOD. n
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Signature of Lonbyisr
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. ~ \ '~-~..~
Signature of Lobbyist: ~ ~,~ rq
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
~i Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn and subscribe efor me
Thisday of 20Q~
SignMUr~ of Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dade
Swor ~d subscri before me
This`~day~pf t~~((~,~~, Z0~
Signature of Public Notary -State of~ida
Notarization of Principal's signature
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'` FOR CLERK'S USE ONLY ,~7 ~~
Annual Registration fee: [ ]Yes [ ~] No Amount Paid MCR # 1/~1~U, ! Date Pai
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doC Revised 12/08/04
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