Michael Marrero/Thomas J. Donell The Palace
City of Miami Beach Office of the City Clerk ZOD6 ACT 2$ AH !~: 13
1700 Convention Center Drive, Miami Beach, FL 3 1.
~ CLL- ~~;i~'S tJF~ ICi
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
spec~cally includes the principal as well as any employee engaged in lobbying activfties. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
NH~~ Ntid~ael J.
NAME OF LOBBYIST: (Last) (First) (M.I)
Ber>JOw F~de11 & F~t~dez, PA, 200 S. Hi~cayne Hlvcl. , Staite 850. Miaiti, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-377238 305-377222 .am
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
~zl~ J. Ixrn11 / rlhe Palace
NAME OF PRINCIPAUCLIENT:
'Ihe Palace 1200 O~tn Lkite N]ia[tli Bi~i FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
517-234-6003 tl~iasic~na71@YaYno.am
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 282 (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:
Arm~ral- at-Id a~r-mr-r-trr- r,f m3tt-cam ml at-Ari try n ~tFi~-Y-a- ;~^fnrrrAr,rp at ~y-
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2~82(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 Clty personnel to be lobbied.)
A Full Name of Individual Title B An Financial, Familial or Professional Relationshi
Platnir~g Bc~d arcrl P1c0'Tlll'Yj I~tI[IErlt 1~tCle
City irn l~rle
testy NHt~r's Office l~le
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required(t $3~0 ~ ~~,
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":
^ Yes ENO: Are you lobbvina on a present or pendina bid for aoods. equipment or services. or on a
present or pendina award for aoods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~ No: Are you lobbvina on a pendina application for a Development Agreement with the City or
application for chance of zoning map designation or chance 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 snot-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
section but, shall not be required to pay any registration fees.
^ Yes No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client: l~
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
~ Personally known (Lobbyist)
0 Produced ID
Form of Id NoMryPub11:-1MtdF1oIN~
• MI- CoIIInIIllfon ElltoilN dell 11'001
Personally known (Print' ~~~~
Solld~d Bir Ntlblal NOtliy Atln.
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This y (7~-~ryr , 2008
n ~ n.
State of Florida, County of Miami-Dade
Sworn d subscribes b me
This day of (/
Sign ure o~licTlotary -State of Florida
Nota ization of Lobbyist's signature
TO B OMPLETED BY CITY CLERK'S STAFF ON `./
Annual Registration fee: [ ]Yes o Amount P E . C # Date Pald D
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\Lobbyist Registration Form 32708.doc Revised 03/27/2008
Notarization of
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~~i Beach City Code and all reporting requirements.
m
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CIN CLERK Office CilyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: 1 s. ~°
I understand that no later than October 1st of each year, 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) 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 immediately notify the Ci Jerk's Office of lobbyist withdrawal in writing.
~ a.~6c.~ 17, 2008
Signature:
Date:
F:\CLERILOBBYIST\Lobbyist Registration Form 32708.doc