Marc Halpern~~~~ ~s
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r' - . 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 enwurage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the Clty Manager or any Gty board or
committee; or any action, decision or recommendation of any Gty 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 tens
specifically includes the principal as well as any employee engaged in lobbying activities. The term °Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3 5
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSIN SS NAME AND ADDRESS ( tuber and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: E AIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
SIN SS NAME AND ADD~tESS (Number and Street) (Ci ) (State) (Zip C e)
7K ~~ r! ti ? . 12JP''
~uf this section If principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNEE~~,,OR BENEFICIAt~Y:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUSTi
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Issue to be lobbied (Describe in detail):
nl. CITY AGEN'C~I~'S~/INDNIDUALS "T.O $E :LOBBIED: Pursuant to City Code Section 2-482(g) include
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a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an Impropriety with any Clty personnel sought to be lobbied -further, pursuant to Clty Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid} from 12 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
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, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~ `~ l
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST OMPENS 10 J
(Required). ~/ U
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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":
present or pendinsa award for goods equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chance of zoning man designation or chance to the Citv'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.
reimbursement. .
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of the foregoing
provisions contained in Section~82 of the P
Signature of Lobbyist:
Signature of PrincipaUClient:
are true and correct end tt{~t I have read or am familiar with the
Beach City Code and all reporting requirements.
Vt. LOBBYIST IDENTIFICATION: r ` f
Produced ID ~L..t~rH yll~'S~1-~~.3~~-t7
Form of Identification
^ Personally known
VII. SIGNATURE AND ST.
State of Florida, County of Miami-Dade ~ ~~~ ~~li
Thisrn t- ~ a~n_d sduasc fb~ efore m ~ ~~'~a~9s~ss~B~~~
ig ature of Publi Notary- State of FI rida c°a?°'oo~~s
Notarization of Lobbyist's signature ~ o_
PRINCIPAL IDENTIFICATION:
C7 Produced ID ~~,{~ ~I (OS4 ~ 7 ~ 3~~~ C7
Form of Identification
^ Personally known (Principa
State of Florida, County of Miami-Dad
Sworn and subscribed before me
This ~2 day of ~ , 2~
of PJblid Notary -State of F
on of Principal's signature
TO BE COMPLETED BY `O~'L~Y CLERK'S STAFF ONLY
:Annual<Registration fee: ,[ ]'Y;es;[ _] No Amount Paid --- MCR #
Lobbyist Registration.Form received and verified by:.
F:\CLER\$ALL\aFORMS\LOBBYIST:FORMS\LobbyistRe9istration-Form 211f] .doc
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@m iam ibeachfl. gov
LOBBYIST NAME: /~~e- ~~ ~~~
I understand that no later than October 1st of each dear, 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.
]) 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.
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Signature: pq
F:ICLER1l.OBBYIST1Lobbyist Registration Form 32708.doc