Jeffrey Bercow/Miami Beach Community Kollel, Inc. (2)
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MIAMIBEACH
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.
Bercow
Jeffrey
NAME OF LOBBYIST:
(Last)
(Rrst)
(M .1)
Bercow & Radell, P.A. 200 South Biscayne Blvd., suite 850
BUSINESS NAME AND ADDRESS (Number and Street) (aty)
Miami, Rorida 33131
(State)
(Zip Code)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
jbercow@brzoninglaw.com
EMAIL:
I. LOBBYIST RETAINED BY:
Miami Beach Community Kollel, Inc.
NAME OF PRINCIPAL/CUENT:
Miami Beach Community Kollel. Inc.
BUSINESS NAME AND ADDRESS
3767 Chase Avenue
(Number and Street)
Miami Beach
(City)
FL
(State)
33140
(Zip Code)
(305) 532-8991
TELEPHONE NUMBER:
(305) 532-8925
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, PARlNER, OR BENEAOARY: Rabbi Yaacov Gross
. IDENTIFY ALL PERSONS HOLDING, DIRECTlY OR INDIRECTlY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARlNERSHIP OR mUST:
II. SPECIFIC LOBBY ISSUE:
Application for variance to Board of Adjustment (BOA).
Issue to be lobbied (Describe in detail):
2/G, l.v yo S?+
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Jorge Gomez None
Richard Lorber None
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RA TE OR OTHER):
I>i) LOBBYIST DISCLOSURE: (Required) $275.00 oer hour
B) PRINOPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $275.00 oer hour
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":
D Yes X No: Are YOU lobbYinG on a present or pendinG bid for Goods. equipment or services. or on a
present or pendinG award for Goods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes X No: Are YOU lobbyinG on a pendinG aPDlication for a Development AGreement with the City or
application for change of zoninG map desiGnation or change to the City's Future Land Use
Map?
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-fur-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..
D Yes X No: Are YOU representinG a not-for-profit corporation or entity without special compensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBM~TO T E CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG LOBBYING EXPENDITURES, ELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE ECED G NDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EX E D S ~~N~DURlNG THE
REPORTING PERIOD. 4/
I do solemnly swear that all of the foregoing facts are true and correct and t
familiar with the provisions contained in Section 2-482 of the Mia I Beach .
requirements.
Signature of LObbyist:
Signature of PrinCipal/Client:
VI. LOBBYIST IDENTIFICATION:
D Produced ID
D Produced ID
Form of Identification
I Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Form of Identification
v. MENDEZ
MY COMMISSION # DD 285215
EXPIRES: January 27,2008
Bonded Thru Notary Public Underwr~ers
State of Aorida, County of I 1-
Swom,i'l,nd subscribed before me . i"
This ~day of I 20QIv
Si of Public Notary Stat f Florida
otarization of Lobbyist's signature
Annual Registration fee: [~] No
FOR CLE
Amount Paid
Date Paid