Jose L. Gomez - Daniel Hertzberg NAIAMI BEACH
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.
Gomez, Jose L.
NAME OF LOBBYIST: (Last) (First) (M.I)
Beilinson Gomez Architects P.A. 8101 Biscayne Boulevard, Suite 309, Miami, FL 33138
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-559-1250 x.208 JG @beilinsonarchitectspa.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address,phone, or e-mail address.
1. LOBBYIST RETAINED BY:
Daniel Hertzberg
NAME OF PRINCIPALICLIENT:
1691 Michigan Avenue, Suite 105 Miami Beach FL 33139 c—,
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-341-7448
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) x
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] - U; -Y R
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: N/A
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SU&C69PORATION,
PARTNERSHIP OR TRUST: P`t/ —� C)
ii.SPECIFIC LOBBY ISSUE:`
Lot Split for property located at 1420 West 22nd Street, Miami Beach, Florida
Issue to be lobbied(Describe in detail):
li(CITY AGENCIES/INDIVIDUALS TO BE LOBBIED;:
Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date,stating the eneral nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
City of Miami Beach Committees and Boards None X
City of Miami Beach Attorneys Office and Administration None X
City of Miami Beach Mayor/Commissioners None X
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,familial or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482 Any Financial,Familial or Professional Relationship
None 9 VU
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) L BBYIST p ISCLOSURE:(Required)
2�oNowr
B) PRINCIPAL'S pISCLOS RE(OF LOBBYIST COMPENSATION):
(REQUIRED). $_250Y�
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 X_No: Are you lobbyina on a present or pendina bid for aoods equipment or services or on a Present or pending
award for goods,equipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_YesX_No: Are you lobbyina on a pending application for a Development Aareement with the City or application for
chance of zonina map designation or chance to the City's Future Land Use Map?
3) Pursuant to Miami Beach City Code Section 2-482(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 a not-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.
_YesXNo: Are you representinq a not-for-Drofit corporation or entity without special compensation or reimbursement
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR,EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES,AS WELL AS COMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEK IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Sign ture of Lo byist Jos L. omez
I do solemnly swear that all of the foregoing fa are true a correct nd that I h ve read or am familiar with the provisions contained
in Section 2-482 of the Miami B ity d all repopti requi ments.
Signature of Lobbyist:
Signature of Principal/Cli nt
VI. LOBBYIST IDEN FICATION: PRINCIPAL IDENTIFICATION:
A
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_Produced ID a ' �. Produced ID
Form of Identification 16 e b Form of Identification
Personally known(Lobbyist) ';° S P��a�L iIDA
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VII. SIGNATURE AND STAMP OF NOTA ;=Commission#EE095186
E E
Expires:ExP MAY 17 20
E N so.-rn9 THxr ATLA.ti c s 15
State of Florida,County of Miami-Dade U v State of Florida,County o� is t-19ke
Swom to and subscribed b fore me : Sworn and subscribed before me
This Wk"` day of w� ,201 This day of ,201 LA
Signature Public Notary—State of lorida -,�o Sig tune of Public No —State of Florida
Notarization of Lobbyist's signatu "'�"olio%% Notarization of Principal's signature
TO BE COMPLETED MY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# 7
2,2 Date Paid
Lobbyist Registration Form received and verified by: ,
D Revised 01/22/2014
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MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachf.gov
CITY CLERK Office
Rafael E.Granada, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 ,Fax:305.673.7254
LOBBYIST NAME: Jose :, Gomez
I understand that no later than February 28 of 28 of each, I must file the following form,
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 AND COMPENSATION 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, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485(d),the City Clerk shall notify any lobbyist(or principal)who
fails to timely file a Statement and in addition to any other penalties which may be
Imposed as provided in Section 2-485.1,a fine of$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 301 of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appeal Miami-Dade County Commission on Ethics and Public Trust.
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