Page 1 of 5 Office of the City Clerk 1700 Convention Center Drive Miami Beach, FL 33139 305.673.7411 LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defe at or mod ification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the C ity 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 i n lobbying activities. Please refer to City Code Chapter 2, Article VII, Division 3 Lobbyists for additional information. Instructions: Please complete all sections of this form and submit the co mpleted form, with the applicable fee, to the Office of the City Clerk . If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular A ny change to any information originally filed, or any additional City Commission er or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form. The lobbyist has a continuing duty to supply infor mation and amend the forms filed throughout the period that the lobbying occurs. Separate registration forms shall be required for each principal represented on each specific issue. I. LOBBYIST INFORMATION : NAME OF LOBBYIST (Last) (First) (Middle Name ) LOBBYIST BUSINESS NAME AND ADDRESS ( Number and Street) (City) (State) (Zip Code) LOBBYIST BUSINESS TELEPHO NE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: NAME OF PRINCIPAL (Last) (First) (Middle Name ) PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street ) (City) (State) (Zip Code) PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant to City Code Section 2 - 482(h)(1)(a): A principal of any corporation, partnership, or other entity who appears as a lobbyist on behalf of that entity, without special compensation or reimbursement for the appearance, whether direct, indirect, or contingent, to express support of or opposition to a n item shall register with the C lerk as r equired by this subsection but shall not be required to pay any registration fees. I f the principal is a Cor poration, Partnership or Trust, the following information MUST be provided pursuant to City Code Section 2 - 482(c): NAME OF CHIEF OFFICER, PARTNE R, OR BENEFICIARY (if none, write N/A) : NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST (if none, write N/A) : American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 II I . ISSUE TO BE LOBBIED : Describe with as much detail as is practical, including but not limited to a specific description where applicable of a pend ing request for proposal, invitation to bid, or public hearing number. IV . CIT Y AGENCIES/INDIVIDUALS TO BE LOBBIED : Pursuant to City Code Section 2 - 482(a)(4) , list the City Comm ission er or City personnel sought to be lobbied, and whether the lobbyist has entered into any contractua l relationship (paid or unpaid ) with said City Commission er or City personnel from 12 months preceding such commencement of service with the City to th e present date, stating the general nature of the s ubject contractual relationship. Full Name of Individual and Title of Person to be L obbied Contractual Relationship ( If yes, e xplain) YES NO P ursuant to City Code S ection 2 - 482(g) , e very 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 Commission er or City pers onnel who is sought to be lobbied as identified on the lobbyist registration form filed. List a ny Business, Financial, Familial or Professional Relationship , or other relationship giving rise to an appearance of impropriety (if none, write N/A) : V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION Be Specific . ( Note that a contingency fee is prohibited pursuant to City Code Sec. 2 - 485.3 ) : American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 The following six (6 ) questions MUST be answered: 1) Pursuant to City Code Section 2 - 488 , e Yes No : Are you lobbying on a present or pending bid for goods, equipment or servi ces, or on a present or pending award for goods, equipment or service? 2) Pursuant to City Code Section 2 - 490 , e Yes No : Are you lobbying on a pending application for a Development Agreement w ith the City or application for change o f zoning map designation or change to the City's Future Land Use Map? 3 ) Pursuant to City Code Section 2 - 48 2 (h) , a ny person (except those exempt from the definition Section 2 - 4 81) 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 city c lerk as required by this section , but shall not be required to pay any registration fees. Yes No: Are you representing a not - for - profit corporation or entit y without special compensation or reimbursement ? 4) Pursuant to City Code Section 2 - 481 , t he term "lobbyist" specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings; any person who only appe ars a s a representative of a neighborhood association without compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not - f or - profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. Yes No: Are you providing only scientific, technical or other specialized information; appearing as a represe ntative of a neighborhood association without special compensation or reimbursement or representing a not - for - profit based organization for the purpose of requesting a grant without special compensation or reimbursement? 5) Pursuant to City Code Section 2 - 491 ( 1 ) , no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s) for whom the campaign consultant provided campaign consulting services within the past election cycle. See Sectio n 2 - 491 for more information. Yes No: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle? If yes, please list the incumbent member(s) of the City Commission: Yes No: If yes, has it been less than 12 months since the elected official(s) whom you provided campaign consulting services was sworn in? 6 ) Pursuant to City Code Section 2 - 48 2 ( a ) (4 )a. , a lobbyist who has within the past election cycle provided campaign con sulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2 - 491) shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particula r service before lobbying the City Commission at a public meeting . Yes No: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle ? If yes, please list the incumbent member(s) of the Ci ty Commission: Yes No: If yes, were you promised or did you receive economic consideration in exchange for campaign consulting services? TO BE COMPLETED BY CITY STAFF ONLY Annual Registration fee: [ ] Yes [ ] No Amou nt Paid $ MCR # Date Paid Lobbyist Registration Form received and verified by: F: \ CLER \ $ALL \ aFORM