Michael Milberg/Mount Sinai Medical Centerr~
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 indudes the principal as well as any employee engaged in lobbying activities. The term
"Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Milberg Michael
NAME OF LOBBYIST: (Last) (First) (M.I)
Mount Sinai Medical Center 4300 Alton Road Miami Beach FL 33140
@USINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 674-2444 (305) 674-2007 mmilbero msmc com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
Mount Sinai Medical Center
NAME OF PRINCIPAL/CLIENT:
4300 Alton Road Miami Beach FL 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)674-2121
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• 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:
Mount Sinai -Miami Heart Institute matter
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional
Relationship
1. Planning Board None.
2. City Commission
3. City staff
4. Health Facilities Authority
5. Zoning Board of Adjustment
5. Health Facilities Advisory Board
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $ 0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 0
X_ Yes 0 No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. Pursuant to Ordinance No 2004-3435
1) Pursuant to Ordinance No. 2003-3393 Amending Miami Beach Citv Code Chapter 2 Article VII Division 5
Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaion Contributions By Lobbyists On Procurement Issues"•
~ Yes X No• Are you tobbvina 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 Ordinance No. 2003-3395 Amendino Miami Beach Citv Code Chapter 2 Article VII Division 5
thereof Entitled "Campaign Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaign Contributions By Lobbyists On Real Estate Development Issues"•
0 Yes X No• Are you lobbvina on a pending application for a Development Agreement with the City or
application for change of zoning map designation or chance to the Citv's Future Land UsP Man?
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 CA DAR YE ATEMENT SHALL BE FILED
EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COM S O U THE REPORTING PERIOD.
Signatur f Lob yist
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. ~ ~ _ , , t _ ,
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
~'~' •~= Form of Identification
,., )
"~-''`~` .Personally known (Lobbyist
VII. SIGNATURE AND STAMP OF NOTARY:
~~~~
~ ~ State of Florida, County of Miami-Dade
~ ~ Sworn to ar~subscrib b ore me
~ g This _,[(_day of 20Q~
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Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
Form of Identification ~+0`''`~%••
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'Personally known (Principal) ~°~;;;t.~
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State of Florida, County of Miami-Dade ~ ~' ~
Sworn a~~ssubscri d fore me ~~ ~ ~
This ~"8ay of 20d ~ ~ ~ o
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Signature of Public Notary -State of Florida
Notarization of Principal's signature
FOR CLERK'S U~S-'E ONLY
Annual Registration fee~•. ~] Yes [ ] No Amount Paid - ~MCR # '- k -' Date Paid~~
Lobbyist Registration Form received and verified by
Revised 02/10/04 F: CLER\ALL\MARIA-M LOBBYIST\LOBBYIST FORM 04
~ First Revision - 05-17-02