Stephanie Martino-Rizzi/Florida Film Institute~~~I
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 indudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435. (' r~ /~
NAME
(First)
AND ADDRESS (Number and S reetj + (City) (State)
I. LOBBYIST RETAINED BY:
FAX , MBE :' .-
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(Zip Code) '
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BUSINESS NAME AND A DRASS -(1~umber and Street) (Ity) (State) (Zip ode)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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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:
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Issue to be lobbied (Describe In aetalq:
ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED; (Pursuant to city Code section 2-4s2(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, gluing 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.)
or
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): /~
(Required). '~/
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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 ljJ.f'ro Are you lobbvina on a present or pending bid for aoods eauipment or services, or on a
present or pendino award for aoods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ILYNo• Are you lobbving on a pendino aaalication for a Development Agreement with the City or
application for chance of zoning map designation or chance to the Citv'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.
(Q Yes ^ No• Are you representing snot-for-profit coraoration or entity without special comaensation or
reimbursement. .
I do solemnly swear that all of the foregoing facts are true and correct ono tnat I nave reaa or am ramwar wun uiC
provisions contained in Section~4~2 owe M~i~~c_ hCity -Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
(!~ Produced ID~~Aylc~a~ ~ ~- - ~ _
Form of Identification
^ Personally known (Lobbyist)
VII.
SIGNATURE AND STAMP OF NOTARY:
State of Florida, County f Miami-Dade
Sworn to and subscrib efo me
is ~_day of , 2008
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee:.[ ]Yes [ ] No Amount Paid $ P MCR# ~-' Date Paid
Lobbyist Registration Form received and verified by: Revised 03/27/2008
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~roduced ID ~~~-M(o3J'7~ ~J--S3- ~~~ ~
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade 6fc~~
Sworn and subscrib d Before me ~9F~'ss~B~
This day of ~X , ( _, 2008 0
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i ature of Public Notary -State of Florida ~G~~O'o~is,
Notarization of Principal's signature ~''~,
V. SIGNATURE UNDER OATH:
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: ~ ~ ~.~.'~r 1 ~~ ~cL ~~~.~-~----
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.
l ~~
Date:
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