Joseph Fred Bliststein/Maria Alarcon
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
wmmittee; 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 wilt 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
to Ordinance 2004 5.
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NAME OF LOBBYI (Last) (First) ~ I (M.I)
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BUSINESS NAME AND ADDRESS , (Number and Street) (City)
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TELEPHONE NUMBER: FAX NUMBER:
I. LOBBYIST RETAINED BY:
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NAME OF PRfNCIPA'UCLIENT: ~p~
BUSINES NAME AN A ESS tuber and treet) (C~ y) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section it 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 ISSU
Issue to be lobbied (Describe in etaiq:
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-4e2(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name
of Individual Title B) An Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLA.'r
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~ ~~ ~ 1 ` ~ n
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION)
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Pr9~urement Issues":
present or oendina award for goods eauiament or service
2)
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real mate Development Issues":
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 anot-for-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
sectio ut, shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
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Signature of PrincipaUClient: Gt~'~'''
VI. LOBBYIST IDENTIFICATION: ~_ PRINCIPAL IDENTIFICATION:
~roduced I ^ Produced ID
of 1 ntification Form of Identification
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^ Personally known (Lobbyist) tl~" Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to ar~d subscribe befor me Sworn and subscrib befoye me
This ~-~S day of ~~.'t~pg,, This ~3 day of / , 2008 O~~"'Yp~~~i~
,~'-'- Joglg.?Ue.~ Tina Powers ,~- ,•o~~••~e,, Tina Powers
'_ '':Commission#DD646123 tit/YcL ^~ .c<Commission#DD64612
Signature of Public Notary - Stag; r pins: MAR, Ol, 201$ignature of Public Notary -State of Expires: ~. O1, 201
Notarization of Lobbyist's si nat~rare~~~`'~ ~~~,, ~w.Aa,RONNoraRr.cor
9 N'H/~'/.AARONNOTARY.co~Motarization of Principal's signature ~~~~~~~
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid S MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\HATL~Forms li.obby-a ~~s:-:~ =+c.•: r;, .,,,nr„- Revised 03/27/2008
~- r ••~o~•~.. .v~ a.uan c V~ GVrllrl ma aeSl nanon or chap a to the Ci 's Future Land Use
Ma°?
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 tF~I~Aiar~i~each_der'aTfd a~reporting requirements.
,.
4
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 i ,Fax: 305.673.7254
LOBBYIST NAME:
CityClerk@miamibeochfl.gov
I understand that no later than October 1st of each aCeor, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1 i Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediate rl~tify the City Clerk's Office of lobbyist withdrawal in writing.
Signatu
F~avisea o~;oa~2oos
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