Jeffrey Bercow/TGNS Dvlpt
~
City of Miami Beach Office of the City Clerk C IT Y
1700 Convention Center Drive, Miami Bach, FL 3313'9
Email: cityclerk@ci.miami-beach.fl.us
LOBBYIST REGISTRATION FORM
RECEIVED
03 APR 30 PH 2: 52
CLERK'S OFF ICE
,.."
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
D 2S Check Box if an Amendment
NAME OF LOBBYIST:
Bercow
(Last)
Jeffrev
(First)
(M.I.) DATE QUALIFIED AS LOBBYIST
200 S. BISCAYNE BLVD.. SUITE 850
BUSINESS ADDRESS: (Number and Street)
Miami
(City)
Florida
(State)
33131
(Zip Code)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
EMAIL:
I.
LOBBYIST RETAINED BY:
TGNC DeveloDment. LLC
NAME OF PRINCIPAUCLlENT:
c/o Bercow & Radell P.A. 200 S. Biscavne Blvd.. Suite 850. Miami. Florida
BUSINESS ADDRESS: (Number and Street) (City) (State)
33131
(Zip Code)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership, or Trust [Section 2-482 (c)l
? NAME OF CHIEF OFFICER, PARTNER OF BENEFICIARY:
Paul Anton
? LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST
IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Substantial Amendment to Conditional Use Permit
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
A) Full Name of IndividuallTitle
B) Relationship
City of Miami Beach PlanninQ Board
NONE
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE:
Hourlv
IlIt?tJ ) /, r.
/
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST COMPENSATION):
Houri
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH FOR THE
PRESEDING CALENDAR YEAR.
D 2S Produced ID
I do solemnly swear that all of the
familiar with the provisions conta. e
amended, and all reporting req Ire
Signature of Lobbyist:
Signature of Principal/CII
VI.
VII.
2S Personally Known
SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
;!' ':,:{~YfU"', LISA C. BROOKS
~:: :,::'~.'A. ~~~ MY COMMISSION # CC 856829
~Il~~:'.' /J..i EXPIRES: July 20, 2003
.~ '-1,j,~ c;F f\,~~., Bonded Thru Notary Public Underwriters
i. '.-fU~"\
V
~
State of Florida, County of Miami-Dade
SWOl;~),o and sltpri~id before me
ThiSoZJ day of f.., 2003.
dc/Kldk-
Signature of Public Notary - State of Florida
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration:
M ACCEPTED
[ ] REJECTED
DATE:
~ '-3() ~ 0 :)
If rejected, state reason:
Registration fee paid:~ Yes [ .1 No 1.Sl~_O_ _
[i rr~ ~Chec~2 MCR #
pATA ENTRY DATE: ~~ ENTERED BY:
1 First Revision - 05-17-02
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISClOSURE:
B) PRINCPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
v. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR.
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 2-482 of the Miami Beach City Code as amended, and all
reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENnFICATION:
a Produced 10
o Personally Known
Form of Identification
VII. . SIGNATuRE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami~Dade
Sworn to and subscribed before me
This day of , 2003.
Signature of Public Notary - State of Florida
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration: [] ACCEPTED
[ ] REJECTED
DATE:
If rejected, state reason:
Registration fee paid: [ ] Yes [ ] No [ ] Cash [ ] Cleek MCR #
DATA ENTRY DATE:
. 2003 ENTERED BY:
2nd Revision 1/27/03
F:\CLER\HAn \Lobbyists\reglstration03.doc