Mark A. Campbell - Chabad on Wheels, Inc.~ m MIAMIBEACH
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
rater to Ordinance 2004-3435.
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BUSINESS NAME AND ADDRESS
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(First) (M.1)
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NUMBER:
Please notify this office if your contact information changes: address, phone, or a-mail address.
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
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BUSINE 5 NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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• 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
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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
personnel' 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) Any 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) N O C~r~+ GO ~~~~/~ _ `
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPE ATION): 'G~(~,~y~
(Required). A/0 l~k-r/j.Or C„~ N- ~ ~yy~IS~QZ D /J
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 lobbvinq on a present or pendinp bid for goods equipment or services or on a
present or pendinp 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":
^^ Y~ No: Are you lobbvinq on a pendina application for a Development Agreement with the Citv or
application for change of zoning map designation or change to the Citv'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 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.
Yes ~ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyi
Signature of Principal/Client:
Vl. LOBBYIST IDENTIFICATION: /
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may' ~' J~"~'s"
~'Produ
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Form of Ide tification
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^ Personally known (Lobbyist)
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wNVi SIGNATURE AND STAMP OF NOTARY:
x ~ ate of Florida, County of Miami-Dade
~ "' orn to d subscribe~?efor me
is /~ day of C..71°~i, ,r2(~1.p
Public
of Lo
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MC -
Lobbyist Registration Forrn received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc
PRINCIPAL IDENTIFICATION:
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~°Produced ID ~.%e~~0~9- ~~- ~9S v
Form of Identification
^ Personally known (Pri
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f'~`,.~'„~'.. MY COMMISSION / DD 879891
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State of Florida, County of
Sworn and subscrib d bef re me
This ~,~d f 1
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Signature f Public ry -State of Florida
Notarizat n of Principal's signature ~~~ F'D~_~~QQ~i
Paid U
Revised
I do solemnly swear that of the foregoi g fa are a nd correct and that I have read or am familiar with the
provisions contained in ection 2-482 of _ ~ ch Ity Cp+1~?r(~all reporting requirements.
m /V~IAMiBEACH
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
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME: ~ Pr ~~< ~ C /~ ~ PQ ~ L (_
I understand that no later than October 1st of each year, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar year with regard to the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation during the reporting period. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADE COUNTY
COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or pay the assessed fines, the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
IN ADDITION, ONCE AN ISSUE I HAVE REGISTERED TO LOBBY ON HAS
SOLVED, I AM REQUIRED TO IMMEDIATELY NOTIFY THE CITY
CLERK'S FFICE OF LOBBYIST WITHDRAWAL IN WRITING.
9 •l3 • ~a
re: Date: