Neisen Kasdin - Miami Beach Community Kollel, 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 mod cation 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 actiyjties..The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. ~
SD~~ Ness~n o.
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i c~crh~Nt Nunnritrt: FAX NUMBER: EMAIL: ~y~~n,~ ~ CQy~
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P/ease notify this,office if your contact' information changes: address, phone, ore-mail address.
I. LOBBYIST RETAINED Y:
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NAME OF PRI IPAUCLIENT:
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BUSINESS NAME D A RE
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... (State) (Zip Code)
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:
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Issue to be lobbied (Describe in etail): ~
ul. CITY AGENCIESNNDIVIDUALS 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.
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IY. DISCLOSURE OF TERMS AND AMOEINTS OF LOBBYIST COMPENSATION (®iSCCC1SE tfiMETkIER HOURLY, FLAT
RATE OR OTHEl~:
A) LOBBYIST DISCLOSURE:. (Requtred) D~/'
B) PRINCIPAL'S DISCLOSURE (OF,C068YiST COMPENSATION): j
(Required). ~ l
The following information must he answered:
1) Pursuant to Miami Beach City Code .Section 2,488 Entitled `Prohibited Campaign:Contributions By Lobbyists
On Procurement Issues°:
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 ortty appears as a representative of anot-for-profit
corporation or entity without speciat.compensation or reimbursement for the.appearance, whether direct, or
indirect, to express support of or opposition to any item, shag register with the, clerk as required by this
section but; shall not be required to pay any registration fees.
Y N ou n: rase ti r rofit o 0 ore w o a co 0
reimbursement. .
V. 3iGNATURE UNDER OATH:
. I do solemnly swear that all of the foregoi
provisions contained in Section 2-482 of i
Si
gnature of Lobbysssr ,_,_
Signature of PrincipallClierrt: _
VI. LOBBYIST IDENTiFtCAT10N:
^ Produced ID
Form of Identification
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ist)
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VII. SIGNATURE AND STAMP OF NOTARY:
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• State of Florida, County of Miami-Dade
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This O' day of
10
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~ Signature of. Public Notary -State cf Florida;
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` Notarimtlon of. La66vist's sigriratrme
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TO 8E COMPLETE
Annual Regtstrafion fee~J Yes [ j No Antormt i
Lobbyist Reg~tration Fomt n'iceived:and verffied by: .
~ FI~LC~: ~.75ff~~~ic'3i+^r'~Q&EC1a d'tL141Y7Ca rnrs iACSt ..t....:t,.., e._~e_
are tare and corned and that I have Head or am familiar with the
Bead City Code and a[I reporting requirements.
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PRINCIPAL IDENTIFICATION:
0 Pt~uced ID
Form o! Identification
ersonaAy known (Principal)
State ~ ride, County. of Mianti~Dade
Sworn ubscribed be me
'T'his ay of 2010
of
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^ Yes ~• Aroe you tobbvina on a areserrt ornendtno bid for woods, eautanrent orservices or on a
aresent or aendinsr ewer for.ooods. eautament or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign ConVrbutions By Lobbyists On
Real.-Estate Development issues°:
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411, Fax: 305.673.7254
. Acknowledgement of fines/suspension .from lobbying for failure, to
comply with City. of Miami Beach lobbying .Laws
LOBBYIST NAME: 1 V ~ I~~ 1 D. ~S~ ~ 1"
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I understand that no later than ®ttobe,~~s# 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-DADS 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
BEEN RESOLVED, 1 AM REQUIRED TO IMMEDIATELY NOTIFY THE CITY
CLERK'S. OFFICE OF LOBBYIST WITHDRAWAL IN WRITING.
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Signature:. - Date: