Lobbyist Registration Form. This is a Florida form and can be use in Miami-Dade Local County.
Tags: Lobbyist Registration Form, Florida Local County, Miami-Dade
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 to Ordinance 2004-3435. NAME OF LOBBYIST: (Last) BUSINESS NAME AND ADDRESS TELEPHONE NUMBER: (First) (Number and Street) (M.I) (City) (State) FAX NUMBER: (Zip Code) EMAIL: Please notify this office if your contact information changes: address, phone, or e-mail address. I. LOBBYIST RETAINED BY: NAME OF PRINCIPAL/CLIENT: _________________________________________________________________________________________________________________________ BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) 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: II.SPECIFIC LOBBY ISSUE: Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's commencement of service with the city to the present date, stating the general nature of the subject contractual relationship. Sec 2-482(a)(4) Full Name of Individual and title of person to be lobbied Contractual Relationship (Explain) YES NO Pursuant to City Code Section 2-482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed. Sec 2-482(g) Any Financial, Familial or Professional Relationship American LegalNet, Inc. www.FormsWorkFlow.com 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)._____________________________________________________________________________________________________________ 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 2) No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a present or pending award for goods, equipment or service? Pursuant to Miami Beach City Code 2-490 Entitled “Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues”: Yes 3) No: Are you lobbying on a pending 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 Map? 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 a not-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. Yes V. No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. . SIGNATURE UNDER OATH: ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. ______________________________________________________________ Signature of Lobbyist 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: __________________________________________________________________ Signature of Principal/Client: ______________________________________________________________ VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID ______________________ Form of Identification Personally known (Lobbyist) VII. Produced ID _____________________ Form of Identification Personally known (Principal) SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to and subscribed before me This ________day of __________, 2011 _____________________________________ Signature of Public Notary – State of Florida Notarization of Lobbyist’s signature State of Florida, County of Miami-Dade Sworn and subscribed before me This _____day of __________, 2011 ____________________________________ Signature of Public Notary – State 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: ______________________________________ F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 1/11/2011 American LegalNet, Inc. www.FormsWorkFlow.com City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: _________________________________________________ I understand that no later than February 28th of each year, I must file the following form, 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 and Compensation 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: ______________________ Date: American LegalNet, Inc. www.FormsWorkFlow.com