Affidavit (URS)
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CITY OF MIlli~I BEACH
OFFICE OF THE CITY CLERK
LOBBYIST REGISTRATION
AFFIDAVIT
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LOBBYIST SPECIFICALI,Y INCLUDES PRINCIPAL AS tmLL AS ANY AGENT,
OFFICER OR EMPLOYEE OF A PRINCIPAL. EACH PERSON WHO tUTHDRAWS
AS A LOBBYIST IS REQUIHED TO FILE A "CERTIFICATE OF
WITHDRAWAL."
(1)
Lobbyist Name gosen, Harold
LAst 'NAME, FIRST NAME
Bus iness phone (3..0.5-) t;, 4 _ 4 7" 7
MI.
Business Address 407 Lincoln Road. Penthouse S.E" Zip 33139
Miami Beach, Florida
(2) Principal Retained By: nR~
a.
Principal's Add'4ess 700 ~ RnY;:!il Pnin.....;;::an;:r, 'Rlvn Zip
(.IE OIFFE~ENT [ROM ADOYE)
#10uu, M~am~ Spr~ngs, Florida 33166
If a corporation, partnership, or trust, identify and provide the
address for the chief officer. partner, beneficiary, or inter~sts.
(3) Subject Matter (Describe in detail!)
~!~y e~ ~~a~! R~;::a~h ~rngr;::am M~n;::agpm~n~ fnr F;::a~ili~~A~
and p.arks.
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(I,) Identify each individual (Commissioners, Board, Committeo, Authority
member, or City staff) to be lobbied.
Miall\i BeaCjlH City..Commis5ion and Mayor
(5)
The subject matter in number (3) nbove is to be considered ntthe
meeting of: (Identify ench entity or individual)
o The City Commi.ssion
o City Commission Subcommittee
o City Staff
a City Board or Committee
o Personnel
o Identify Others
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(6) State the extent of any business, financial, familial, professional or
other relationship which exists with any individual identified in number
(4) above.
None.
ON JULY 1 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK, A
SIGNED STATEMENT UNDER OATH, LISTING ALL LOBBYING EXPENDITURES IN THE
CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR.
I do solemnly swear that all of the fore oing facts arc true and correct
and that I have read or am familiar wi ' the provisions contained in
:::::::::~::'::b:::s:~ami Beach CitX OdQ~n ,nnd all reporting
..
o Personally kno.~
o Produced ID
(IUEllTI Fn
o Did take an oath, or
o Did not take an oath
State of Florida, County of Dade
Sworn to and subscribed before DIe
this /;;!1;, day of t.o \l\.I.' L f>.~~
LAURA CJJ<<) Notary
I
'J" .... MyCcmm E>ql.1I13104
\: f .Je. No. CC 901893
'\. '. PertGftIIlYl(IWIWn 11QlherI.D.
Noto . Dmp. or Type os Commissioned
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Registration:
fOR.CLERK'S USE ONLY
o REJECTED
DATE "3 - / - A /
I
If rejected, state ronson: ~
Registration fee paid: ~
o Cash
o No ,0
~D
o Check
Not For Profit Organization
~~~u~:~ ~o~~hed
ENTERED BY
DATA ENTRY DATE
19