Michael E. Bath/National Gay & Lesbian Task Force
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
spec'rfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
OFOF LOBBYISM (Last) (First) (M•q
r~ C-s~.--, ~~ ~e``o`~.,~, ~-~F ~c.~. ~. ~1~,~ 3S\C~~•~c~.-. ~~.,c9. ~Z~Z ~~w.'. `FL 33137
ESS NAM AND ADDRESS (Number and Street) (City) (State (Zip Code)
FAX NUMBER: EMAIL:
ZGd4.~
BUSINESS NAME AND ADDRESS (Number and Str (city) tstate~ ~-+ trip i.uuei
X62 ~ 3y~-S'\~ 2052- ~ 3- 22~ \
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optlonal)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~p~ ~G~c7, ~~~~~L~ ~ 5~~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MOIRE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: N ~ t~ _
~1
Issue to be lobbied (Dessube in detail): ~
ul. CITY AGENCIES/INDIVIDUALS TO BE .LOBBIED: (Pursuant to city code section z-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.)
Individual Title
f
A Full Name o B) An Financial, Familial or Professional Relationship
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D
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I. LOBBYIST RETAINED BY: -^
~~ Qn ~\ ~ c--, ~v.CJ~ ~e,`O: c_ :~ \ a-.3~ _ ~C) ~C~ ~i Uia~~ C~ c-..\~ G ~~
u.SPECIFIC LOB6Y ISSUE:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required
~ _ ~L. _ > _~ :. ~ ~ \~ - ~ rte.. e y~ LC~ V--c~-.. c~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). ~ ~ ~~ c, .r C-
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 o• Are you lobbvina on a present or pendina bid for aoods equipment or services or on a
present or pendina 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 No• Are you lobbvina on a pendina application for a Development Agreement with the City or
application for chance 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. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: / ~
Signature of Principal/Client:
VI. LO YIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
„~ ~
Produced ID ~ _ Produced ID
Form of Identifi io Form of Identifi
c~~
^ Personally known (Lobbyist)° ~ ~ ^ Personally known (Principal)
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VII. SIGNATURE AND STAMP OF N '~;~
4
State of Florida, County of Miami-Dade ~~~ State of Florida, County of Miami
Sworn to a s scribed efor me ~ Sworn and syi~scribe befo me
This -~~~, 2008 ~„ This y of , 2
+~ ~~' '
Sig a ure ublic o a - of Flor ~,,t`~ Si ature of otary -
Notariza on of Lobbwst's signature Notarizatio of Principa
T(7 6E COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ J Yes [ l J No Amount Paid $ ~--- MCR # Da'
Lobbyist Registration Form received and verified by: ~~/ - // ~-
c iZ 3
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~~~
`ice W
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are
a zzol~
Paid
sed Q3/27/2Q08
I do solemnly swear that all of the foregoing facts are true and rrect and that I have read or am familiar with the
provisions contained in Section 2-482~ftheJ)liaryti'~ea~~ C~e~i all reporting requirements.
...a. W
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CilyClerk@miamibeachfl.gov
LOBBYIST NAME: ~l ' \ ~ ~~-- ~~ ~ G-~`"
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
2J 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.
Signature:
~ o ~ 22 tam
Date:
F;i~Ef~tL.f~Yf>T~~,c~b~ayi~~ F~ec~i~trYi€~rt _ ~ ~ ,c"