Roberto Shavin/Center for the Advancement of Jewish Education~ ~
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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 tc 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
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
NAME OF LOBBYIST: (Last) First) (M.I)
BUSINESS NAME AND ADD SS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL• C~~~ _ rb ,` ~
FAX NUMBER: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NA~ME /O~F~ CHIEF OFFI ER, PARTNER, OR BENEF~IARY:
.VV: t-+Y-1ZWo~ •~~~ ~ ~ G~ G4'~." GO 4 Nal- ~iG3
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP ORrTJRUST:
u.SPECIFIC LCIBBY ISSUE: M
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Issue to be lobbied (Describe i detail):
ul. CITY AGENCIES/INDIVIDUALS TO B'E LOBBIED: (Pursuant to City Code section 2-4s2(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) Any Financial, Familial or Professional Relationship
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BUSINESS NAME AND ADDRESS (Number and. treet) (City) _(State~ _ _ •_ _ _ (Zip•Code)
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHERJ:
A) LOBBYIST DISCLOSURE: (Required) ~, G l ` X
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST OMPENS(~TION): X.
(Required). Cl~ ~•~
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 LI NO: Are you lobbying on a present or pendina bid for Goods. equipment or services. or on a
present or pendina award for goods, equipment or service? r-~ ^'
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2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists-Qn "'
Real Estate Development Issues": ~-, ~..
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^ Yes No: Are you lobbyina on a pendina application for a Development Agreement with the Citi~r O
Map? t;j ~
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3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the defiilltibn dtV
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of a not-fps-prof.
corporation or entity without special compensation or reimbursement for the appearance, whether diE-ect, o~•
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.
•lQ Yes ^ No: Are you representing snot-for-profit corporation or entity without special compensation or
retmbursement. .
V. 51GNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client: `"~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
,_/' Form of Identification
NJ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom to nd subscribed before me
This ~ day of _~~~ __,~2@@~ ~Qfp~
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Signature of Pubic Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
0 Produced ID
x
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Form of Identification tray a
.,~ ; •• .`;`~, SANDY R NIEiI'T1~AY1
~~av ~~ * ~ MY COMMISSION # DD 8378p
?°;•••;~~^ 1'i8111JVFiR'i3VQ(i~(Principal) EXPIRES: February 17, 2011
* * MYCOMMISSIONtDD637929 °~+~~~~a°e g~~e~~g
a EXPIRES: February t7, 20t i
r'~~ Fl,~`O! bonded lhru Budget Ndary Services
State of Florida, County of Miami-Dade
Sworn d subscribed before me l~,
This day of @B-- C~j J
~--s
~~.
'- Signature of Public Notary- tate of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY RK'S STAFF ONLY ~~
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date. Paid
Lobbyist Registretion Form received and verified by: /~- n
F:\CLER\LOBBYIST\Lobbyist Registration Form 327gB.doc Revised 03/27 2008-'
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 Qjty Code and all reporting requirements.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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 ~NO: Are you lobbvina on a present or pending bid for woods. eauipment or services. or on a
present or pendina award for Goods. eauipment 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 change of zoning map designation or change 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 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
section but, shall not be required to pay any registration fees.
^I/J 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:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification
Personally known (Lobbyist) ~°`;~a''~~`~o^ Y~BII1fM(Principal)
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*
* MY COMMISSION a OU 637H2u
VII. SIGNATURE AND STAMP OF NOTARY: as, ~ EXPIRES: February 17, 207 t
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BOaded ThN Budget Notary Services
TFOF F~~
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to d subscribed before me
~
~ Sworn and subscribed before me
This
day of ~1 ,2665 ~Ot`> This day of , 2008
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Signature of Pubic Nota`ry'State-of Florida -"'-
Notarization of Lobbyist's signature
Signature of Public Notary -State of Florida
Notarization of Principal's signature
X
X
x
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]. Yes [ ] No Amount Paid a- MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\LobbyisERegistration Form 32708.doc ReVlsed 03/27/20013
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 gjty Code and all reporting requirements.
m i
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME:~~~~ ~6~A
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 City Clerk's Office of lobbyist withdrawal in writing.
Sig tur Date:
F:ICLER\LOBBYIST\Lobbyist Registration Form 32708.doc