Roberto Sanchez/David Tornek4
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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 t~o,~Ordinance 2004-3435.
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY: r~
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BUSINESS NAME AND
(Last)
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(Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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 detail):
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ot. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of IndividuallTltle 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) Q "') ~~ ~1P~
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
^Yes ~DIo• Are you lobbving on a pending application for a Develoament Agreement with the City or
application for change of zoning map designation or change 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.
reimbursement. .
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V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS _V11 E_LL A COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALEND YEA A TATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES O PE SATION URI G THE REPORTING
PERIOD. ~
Signature of Lobbyis
I do solemnly swear that all of the foregoing facts nd correct and that I have read or am familiar with the
provisions contained in Section 2-482 o e Mia Be h ity Code and alf reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
LOBBYIST IDENTIFICATION: PRIN IPAL IDENTIFICATION:
Produced ID ~-~ ~ SS~~a ~~OC~,~/~v~b roduced ID ~~m~ ~~o ~lP~ ~~`~ v
Form of Identification Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribe of a me
This ~~,~LG _day of , 20~~
ignature of PublicNotary - Stat~.Uf Florida
otarization of Lobbyist's signature
^ Personally known (Principal)
State of Florida, County of Miami-Dad
Sworn nd subscri bef a me
This day of , 20~
5=(gnature of Public Nofaiy - Site of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ] Yes No Amount Paid $
MCR # /~ Date Paid
Lobbyist Registration Form received and verified by:
Revised 02/04/2008
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2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues':
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachil.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
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 J 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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CityClerk@miamibeachfl.gov
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Signatu.r~:
Date:
Revised 0210412008
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