Shubin John K/Lloyd Mandell
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Miami Ileath
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
NAME Of lOBBYIST:
(Rrst)
M ('tLrYl i
(last)
4(P S_W. l tk stree.}
BUSINESS NAME AND ADDRESS (Number and Street) (Oty)
(;05 \3E)1 ~ ~O(oD {~O'Sj 38/- C(4?7
ONE~BER: NU :
I. LOBBYIST RETAINED BY:
---1:\ It . <.. ~J M a "'" J" d
NAME OF PRINOPAljCU :
DeCb ~ ~~ ~,,"\S, L4J. 11~ \ (DII,V\.s A~ \1.g~1 PL
BUSINESS NAME AND ADDRESS (Number and Street) (City) I (State)
?P 3-''i~D 30 03- 1'-1 (P
TELE FAX NUMBER: (Optional)
:$ 3>,.3 I
(Zip Code)
EMAIl: (Optional)
Fill out this section if ptlncipal is a Corporation, Partnership or Trust [Section 2-482 (e)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:
D. SPECIFIC LOBBY ISSUE:
o .l!iL..Q u ~ l + t '^'" -\- \;J \oJ IA.-r- l ,. .......A I
Issue to IJeIObbied (Describe in detail):
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m. CITY AGENQES/INDMDUALS TOeE LOBBIED:
A) Full Name of Indlvldual/ntle B) Any Finandal, FamlUal or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS Of LOBBYIST COMPENSAll0N (DISCLOSE WHETHER HOIJRL Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISUOSURE: (Required) H \:) \..J. 14-"- -, ~ ... 'T c.... / -tl +.5 \) ~ ~I'L.
B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Ho~a..L '( ~A--r:~ / R~ t.-kou~
The following infonnation must be answered:
1) Pursuant to Miami Beach aty Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
D Yes ~o: Are vou IobbvinG on a oresent or oendina bid for aoods. eauiDment or services. or on a
Dresent or oendina award for GOOds. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues": -""
DYes ~o: Are vou 10bbvinG on a oendinG a'oolication for a Develooment AGreement with the CitY or
aDoIication for change of ~ninG maD desianation or change to the CitY's Future Land Use
Mu1
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 a not-for-proflt
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 derk as required by this
section but, shall not ~ required to pay any registration fees..
D Yes )'&0: Are vou reDresentinG a not-for-Drofit corooration or entitY without soedal comoensation
or reimbursement. .
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, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
~ -~... '\-::-- ---~
Signature of Lobbyist
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 and all reporting
requirements.
9gnatureof~st: ~ ~
SIgnature of Princlpavaient: _: _n_ .. _ __: _ o^ ~
VI. LOBBYIST IDEN11FICAllON: PRlNCPAL IDENTlFlCA1l0N:
o Produced 10 0 Produced ID Fp L. N S~"f S 31l.f 7'1/'" 0
Form of Identification Form of Identification
)(;ersonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
o Personally known (Principal)
;~~2,':"\\J NUMf",c.",)
,~PO~S3'11 ~-j 1
''':',~iON E)(P/F:'",
f '-.j
Signature of Public
Notarization of
FOR
Annual Registration fee: [ Yes [ ] No Amou
Lobbyist Registration Form received and verified by:
F:\UER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM . oc
~~ ,d;27b 6 tY( Date Pai
Revised 12/08/04