Marcia Jo Zerivitz/Jewish Museum of Florida
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MIAMI 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
Oty 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.
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NAME OF LOBBYIST: (Last) (First) (M.!)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 7
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TELEPHONE NUMBER:
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FAX NUMBER:
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I. LOBBYIST RETAINED BY: ,SIll! ~~
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NAME OF PRINCIPAL/CUENT:
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(City)
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(State)
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(Zip Code)
BUSINESS NAME AND ADORE
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TELEPHONE NUMBER:
(Number and Street)
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-4B2 (cl]
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be iobbied (Describe In detail):
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III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
Al Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLA T RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
DYes 1J.l('0: Are YOU 10bbyinD on a Dresent or DendinD bid for Doods. eauiDment or services. or on a
Dresent or Dendino award for Doods. eDuiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitied "Prohibited Campaign Contributions By Lobbyists On Real
Estate Oevelopment Issues":
nves ndrI'&: Are YOU lobbvinG on a oendina BDDlication for a DeveloDment AGreement with the City or
aDDlication for chanGe of zonina maD desiGnation or chanGe to the Citvls Future Land Use
MaD?
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-profit
corporation or entity without spedal 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..
iJo't'es 0 No: Are YOU reDresentinD a not-for-Drofit corDoration or entity without sDecial comDensation
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.
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Signa r of Lobbyist
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I do solemnly swear that all of the foregoing facts are true and 6rrect and th lave read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. M A _' /
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Signature of Principal/Client: .
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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Form of Identification
~rsonallY known (Lobbyist)
o Produced ID
o Produced ID
Form of Identification
g(ersonally known (Principal)
~..."':S.. ROBERTA H. GORDON
.." VI' MY COMMISSION # DO 243470
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VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swor 0 .and iSCIi\l~efore me .."
Th1 1I2i a'i._of j,QA/tlAAY' . 20~
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,signature f ublic Notary - State of Florida
LNotarization of Lobbyist's signature
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