Michael Epstein/M. Epstein Spirits Productions, Inc.
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.
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NAME OF LOBBYI T: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) ity) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
~] , + C'~S'Ft`^ r~J f~~~~.~~~~,1 ~ik State) (Zip Code)
BUSINESS NA E AND AD ESS (Number and Street) (City)
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:
u.SPECIFIC LOBBY ISSUE: n ~`
~r~n ~ rlg vI.'~ -1Cr / V ~~~ ~A J~v`~- ~r' f;, ~ ~r1 A ~~/,l
Issue to be lob ied (Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(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.)
A Full Name of Individual/Title B) An Financial, Familial or Professional Relationship
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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): ~ ~ ~
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 ~ No• Are you lobbvinp on a present or pendinp bid for aoods, equipment or services, or on a
present or pendinp award for aoods equipment or sernce?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~ No Are you lobbvinp on a pendinp application for a Development Agreement with the City or
a lication for change of zoning map desianatlon or change to the Clty 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 snot-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 ~ No Are you representing a not for profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: / ~ '' " ~~
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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^ Produced ID ~ ~- ~~ ~~~' ~ ~ ~ roduced ID °
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Form of Identificati g a.~ orm Identification
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~,Laa~ ~t~,~~P~mna'~j~ Lobbyist) ~ ~ ~ ~ ^ Personally known (Principal)
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VII. ~ ~ r ~N STAMP OF NOT . ~ "'
State of Florida, Cou Miami-Dade k~~yo,, State of Florida, County of Miami-Dade
Sworn to and subscribed before me ~~.... ~a_ Sworn and subscribe before me
This ay f J1/~ / , 2 =':~ This ,~lf~day 0 V• , 2008
Signature of Public Notary - Sta 'of Florida natu to of Florida
Notarization of Lobbyist's signature Notari anon of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF O LY ''
Annual Registration fee: [ Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Form received and verified by:
,~ y Revised 03/27/2008
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 2-48 of th~rMiaAmi Beach City Code ~d all reporting requirements.
m
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LObdY15T NAME: ~-
I understand that no later than October 1st of each veer, 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
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.
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- Date:
Signature: