Bercow Jeffrey
lA
..."
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 defined in any manner in this section, 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.
NAME OF LOBBYIST:
Bercow
(Last)
Jeffrev
(First)
(M.I)
200 S. Biscavne Boulevard. Suite 850
BUSINESS NAME AND ADDRESS (Number and Street)
Miami
(City)
Florida
(State)
33131
(Zip Code)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
ibercow(Cilbrzoninolaw,com
EMAIL:
I. LOBBYIST RETAINED BY:
Joseph W. Blount
NAME OF PRINCIPAL/CLIENT:
2535 Lake Avenue, Sunset Island No.2. Miami Beach
BUSINESS NAME AND ADDRESS (Number and Street) (City)
Florida 33140
(State) (Zip Code)
FAX NUMBER: (Optional)
EMAIL: (Optional)
TELEPHONE NUMBER:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)l
. 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:
Variance Application in connection with Single-Family Residence
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional
Relationship
Board of Adjustment NONE
City Staff NONE
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $425.00 houri v
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
$425,00 hourlv
n Yes Il!I No: Are YOU reDresentinG a not-for-Drofit corDoration or entity without sDecial comDensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach Citv Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
n Yes Il!I No: Are YOU lobbyinG on a Dresent or DendinG bid for Goods. eGuiDment or services. or on a Dresent
or DendinG award for Goods. eGuiDment or service?
2) Pursuant to Ordinance No, 2003-3395 Amendina Miami Beach Citv Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
DYes Il!I No: Are YOU lobbyinG on a oendinG aDDlication for a DeyeloDment AGreement with the City or
aDDlication for chanGe of zoninG maD desiGnation or chanGe to the City's Future Land Use MaD?
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of th
am familiar with the provisions nt
reporting requirements.
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST S ALL U
STATEMENT UNDER OATH, LISTING LOBBYING EX ND
IN THE CITY OF MIAMI BEACH FOR THE PRECEDI G CA
EVEN IF THERE HAVE BEEN NO EXPENDITURES CO
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: P
[J Produced ID
.(Produced ID
tJti '('f' U t, fR1 k
Form of Identification
Form of Identification
~erSOnallY known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
[ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~ day of- , 20Q)
State of Florida, County of Miami-Dade
Sworn and subscri efore me
This ~day of u1lo 20a;
Signature
Notarizatl
,WIlCLE.RJ('S USE ONI,)) ""1~~/~')"
!b1'i..lJ1V of. r I' "
Annual Registration fee: [--rYes [ ] No Amount Paid CO . CR #~7 ~
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F: CLER\A -M\LOBBYIST\LOBBYIST FORM 04
1 First Revision - 05-17-02