Lee Brian Schrager_ ~ 4
City of Miami Beach Office of the City Clerk ~, ~ y..~
1700 Convention Center Drive, Miami Beach, FL 33139 ~: -o ~'
LOBBYIST REGISTRATION FORM ~> ~ ;~Z
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification a~•
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city beard
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on,sucFT'-
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 20043435.
Membiela Milli
NAME OF LOBBYIST: (Last) (First) (M.I)
7300 NW 19st Suite 502 Miami FL 33126
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 471-9750 (305) 471-9754 membiela@bellsouth.net
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
Housing Authority of the City of Miami Beach - Miguell Del Campillo
NAME OF PRINCIPAUCLIENT:
200 Alton RD Executive Office Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 532-6401 ext 3020 (305) 674-8001 Mdelcampillo@mbha.org
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:
City of Miami Beach purchase of 17th Street Property
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include
a statement of the extent of any- business, financial, familial, professional or other relationship, giving rise 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 said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Individual Title B An Financial, Familial or Professional Relationshi
i~7 IV H iV C~ C~oM t'~'~ ( ~`GiZ
Cnc~ Sfi~.G
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOB YIST DISCLOSURE: (Requires)
B) PRINCIPAL'S DISCLOSURE (OF L,Q~B _ hCON~ENSATI~
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":
~ present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chanae.of zoning map designation or change to the. Citv's Future Land Jse
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 PriricipailCiient:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID ~/h
F rm of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn t an~ r ®o~pg]pp,
This '
~ 53
Sig re of ~ S of or'
NotarizatiorB®fded6 i~g~9~~ Co., c.
PRINCIPAL IDENTIFICATION:
^ Produced ID N~~
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dad
Sworiya subscribed before me
This day of ~~~~
~,14?n.
Signature o ubli y d a
Notarization of Prin I'~sii~t~ty
Ann a i13nUC
e
TE 0 ORIDA
r1 _TOS.
' 253
~', 4, 10
Bonding Go., Inc.
TO BE COMPLETED BY CITY RK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ R # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\LObbyist Registration Form 21109.dot Revised 02/11/2009
r~7~ ~ °
~~
I do solemnly swear that a •~re of f cts are true and correct and that I have read or am familiar with the
provisions contained in Se i $2 0~ ~rrRij Beach Cjty Code and all reporting requirements.
~~-_ ~
City of Miami Beath, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miam ibeachfl.gov
LOBBYIST NAME: M ~ "i M~2Y1~~~
I understand that no later than October 1st of each year, I must file the foNowing
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 imm lately noti the City Clerk's Office of lobbyist withdrawal in writing.
,~
~a a~(
Signature:
Date:
F:\CLERIt_OBBYISTILobbyist Registration Forrn 32?08.doc