Douglas W. Tober/SMG
City of Miami Beach OfFice of this City Clerk
1700 Convention Center 17rive, Miami Beach, F~ 33139
LOBBYIST REGISTRATION PORN
Lobbyist means AA persons empbyed or retained, Whattlar paid or not, by a principal who seeks to en~urage the passage, de~eat or modification of
any ordkianca, resolution, action or decision of any commissioner; any action, decision, recommendation bf th@ Clty MAna9or or any city board or
eommMtno; or anY action, dRei9ion or n~eemmendatkfn of any city perxonnel during the time perbd of the entire declskrn-malting process on such
action, decision or recommendation that forososabfy will be heard or roviowcd by tnc city eommisslon, or a clry hoard or committee. The term
apeclfkally Ineiudea tfie prlnc~al as well as any employee engaged In lobbying activltiBS, Tb9 farm "L,ehhytats" has apeeifle sxelustona. P'leeae
refer to Ordinance 2008-3b35.
"7"od pa' ~~~or~C ~a s vi1
NAME OF LOBBYIST' (Last) (First) (MJ)
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BUSINESS NAME AND ADDRESS
' (Number and treat) (City)
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r (State)
~ (Zip Gode)
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TELEPH NE NUMBER: FAX N MBER: EMAIL;
1.
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUS S AND ~~'~pDRESS {Number and Street) (City) (State) (Zip Coda)
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TELEPHO E NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal Is a Cvfporatlon, Partnership or Tru
• NAME OF CWIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLbING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP 012 TRUST;
11.SPBCIFIC LOBBY ISSUE:
~Q~P 2r~ -- a7~o~ ~~ ~f__a_ F ,L~r~~~ c~ ~n~~io~
Issue to be lobbied (Describe i detail);
III. CIT1f ,AGENCIES/INDIVIDUALS TO BE LOBBIED: (pgrsvant to city code section a-asa(g)
Include a statement of the extent of any Dusinesa, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be Iehbled; further, pursuant to Ciry Code Sevtlvn 2-
482(a)(A) Inclutle $ statement o! any contractual relationship (paid or unpaid) from 12 months preceding the
cvmmoneAmant of service of City personnel to be lobbied.}
A Pull Neme of Indlvidudl Title B) Any Financial, FBmill8l or Profosslonal Ralationahi
C~~ /~a-ta ei~ ItJa
or k ~~+~, ~s,o~s /~,fo
1V, DISCLOSURE OF TERMS ANt) AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WMETHE~t HOUI2~CY, FLAT
RA TE OR OTHER):
A) LOBBYIST DISCLOSURE; (Required) - Q .-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): r
(Required}.
Th® following information must be answered:
1) Pursuant to Miami Beach City Code Section 2.488 Entitled "Prohibited Campaign Contributi~~ns By Lobbyists
On Procurement Issues":
Y®s ^ No' Are Vou lobbyins~on aloJrese~to~endlna bid for goodsteaaipment or services,_o~r a~a a
present or pendina award for Qoods. equipment or_service3
2) Pursuant to Miami Beach City Code 280 Entitled "Prohibited Campaign Contribu#ions By Lobbyists On
Real Estate Development Issues":
^ Yes V_1 No: Are you lobbyinsl on a.pendinQ.apolication for a Develo_oment_AQree~LeQ,t~t~Sb~e C1t_v_~r
application for ohanae of zoning map desianatlon or change to the Cltv's Future,Land Use
MoD?
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 c,f a not~for profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or oppositien to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
^ Yes ~NO: Are you representina.a not-for-profit corporation or entity without special compensation or
t'eI bursement~ .
V. SIGNATURE UNDER OATW:
I do solemnly swear that alt of the foregoing facts are
provisions contain®d in Section 2~ f th Mia i Bea
Signature of Lobbyist
Signature of Principal/Client:
VI. LOHgYIST IDENTIFICATION:
^ Produced Ip
Farm of Ident~cation
®rsonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dads
S n nd subscribed ba ore me
d y f , 2006
l' ~~ ,,
Signature of ublic Notary -Stet of Florida
Notarization of Lob~,b~lst's signature
F:
and correct and tha# I have read or am familiar with the
:ity Code and ell repor#Ing requirements.
PRINCIPAL IDENTIFICATION:
~ Produced ID ._
Form of Identification
Personally known (Principal)
/ ~ ~I'[.cxeL
State of~Flefideh County of~ARian~i-Bade
Sworn an subscrib before me
This av of .2008 ~
v ~
gna a of Public N ry -State offi-turlda ,~
otarization of P_[irtcipal's signature
TO BE COMPLETEb (3Y CITY
Yes ~ ] Na Amount Paid ~_
calved and verit3ed by:
glseratipn Form 327Q8.doc
C,-ny v~ ....~.- ~ duq o, ~...
My ~,rtiission E~
1Jlember, Pennsalva"~A gsso''iatioo of Notaries
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Signet of Lobbyist
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City o4 aVAiami 6maCh, 1700 Convention Center Drlve, MEaml f3~aeh, Florldo 33139, v+ww.miamibsochfLgov
CITY CLERK Office CilyClork@miamiboachfl.gov
rel: 305.673.7411 ,Fax: 305,673.7254
LOBBYIST NAME: ~a~c~/~S ~ ~ ~~
I understand that no later than October 1st of each xear, k 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.
~- ~ e2 ~ ~~
Signature: pQ ; ~~
F:1CL~RILOBBYIS'rlLobbyist Registration Form 3270~i,doc