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Page 1 of 2 Office of the City Clerk, 3500 Pan American Drive, Miami, FL 33133 / Phone: (305) 250-5361 / Email: email@example.com CM-LRF (Rev. 06/19) Note: Annual Registration Expires on 12/31/2019 CITY OF MIAMI LOBBYIST REGISTRATION FORM Instructions: Please complete all sections of this form and submit the completed form, with the applicable fee(s), to the Office of the City Clerk. If you need more space to complete a section, use a separate sheet(s) of paper. If you have nothing to report in a particular section, you must type or print 223None224 or 223N/A224 in that section. IF ANY SECTION IS LEFT BLANK, THE FORM WILL NOT BE ACCEPTED. Important: It is the responsibility of the lobbyist to ensure that ALL active lobbyist registration forms, including active lobbyist registration forms submitted in previous years, remain up-to-date. (1) Lobbyist Name: (Last Name, First Name, Middle Initial) Are you a Principal of the corporation, partnership, trust, etc.? YES NO (you must check YES or NO) Business Phone: Email: Business Address (include Zip Code): (2) Principal Represented: (Name of corporation, partnership, trust, etc., you are representing) Business Address (include Zip Code): (3) IF YOU PROVIDED INFORMATION IN SECTION 2 ABOVE, PLEASE REVIEW THIS SECTION CAREFULLY. If a lobbyist represents a corporation, partnership or trust, the lobbyist must disclose the name and business address of the chief officer, partner or beneficiary of the corporation, partnership or trust, and the names and addresses of all persons holding, directly or indirectly, at least five percent (5%) ownership interest in said corporation, partnership or trust. Attach separate sheet if needed. If this section is not applicable you must type or print 223None224 or 223N/A224. (4) Specific issue associated with lobbying. Describe with as much detail as is practical. Attach a separate sheet if needed. If you are using this form for your Annual Registration, please write 223Annual Registration224 and the year that you are registering for (ex: Annual Registration 2019). American LegalNet, Inc. www.FormsWorkFlow.com CM-LRF (Rev. 06/19) Page 2 of 2 (5) Lobbyists shall be required to state the existence of any direct or indirect business association, partnership, or financial relationship with the Mayor, any member of the City Commission, any member of a City board, the City Manager or a member of the City staff before whom he/she lobbies or intends to lobby. Attach separate sheet if needed. If this section is not applicable you must type or print 223None224 or 223N/A224. Lobbyists, as defined in City Code Section 2-653, shall pay an annual registration fee of $525.00, plus $105.00 for each principal represented for each issue lobbied on behalf of any one principal. Each issue associated with lobbying shall be described with as much detail as is practical. The City Clerk, or the City Clerk222s designee, shall reject any registration statement that does not provide a clear description of the specific issue on which such lobbyist has been retained to lobby or if any section of this form is left blank. Regardless of the date of the annual registration, all lobbyists222 annual registrations shall expire December 31 of each calendar year and shall be renewed on a calendar year basis. Each lobbyist shall, within sixty (60) days after registering as a lobbyist, submit to the Office of the City Clerk a certificate of completion of an ethics course offered by the Miami-Dade County Commission on Ethics & Public Trust (223Ethics Commission224). Lobbyists who have completed the initial ethics course mandated by the preceding sentence and have continuously registered as a lobbyist thereafter shall be required to complete a refresher ethics course offered by the Ethics Commission every two (2) years. Each lobbyist who has completed a refresher ethics course shall submit a certificate of completion within sixty (60) days after registering as a lobbyist. I do solemnly swear that all of the foregoing facts are true and correct, and I have read or am familiar with the provisions contained in Chapter 2, Article VI, Sections 2-651 through 2-658 of the Miami City Code, as amended. Signature of Lobbyist STATE OF COUNTY OF Sworn to (or affirmed) and subscribed before me this day of, , by . (Name of person making statement) Signature of Notary Public Name of Notary Typed, Printed or Stamped (NOTARY SEAL) Personally Known: OR Produced Identification: Type of Identification Produced: FOR OFFICE USE ONLY: Check # Receipt # American LegalNet, Inc. www.FormsWorkFlow.com