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Melvyn Schlesser - Chabad on Wheels, Inc.~ ~ MIAMIBEACH c~ ~ ~.~~ ~~~ N'~~ 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 or 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 toreseeably 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 2004-3436. t~-. ~Lt~i~- G`f L ~C~ NAME OF BBYIST. (Last) (First) ( ,I) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) ~d~- 5 ~ / - 3/5 .5 3©s_ 53 i-~/ ~3 ~~r-P~~O~ ~y ,®~dL TELEPHONE NUMBER: FAX NUMBER: EMAIL: ~ ~~ Please notify this office if your contact information changes: address, phone, or e-ma11 address. I. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: ~wc~z~ ~ ~ ~~'~~r ~~~ ~ c ~~i3~ BUSINESS NAME ND ADDRESS (Numbe and St et) (City) (State) (Zip Code) (Optional) wt this section If principal is a Corporation, Partnership or Tru • 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: n.SPECiFiC LOBBY ISSUE: e ~~ Giw~ol.w ~ i~P ~ ~oti`~~ se ° ;-L w Lam. Issue to be lobbied (Describe in detail): - _ . Ili. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(8) include . a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety with any City personnel sought to be lobbied -further, pursuant to City Code Sectio_ n 2- . -482{a)(4) include a statement of any contractual relationship (paid. or •unpaid) from 12 months preceding said City personnel' commencement of .service with the City to the present date, stating~•the general nature of the subject contractual relation. A Full me of Individual Title B) Any Financial, Familial or Professional Relationship ~7~~~~ ~~ ~d ~! ~ _~ o10Z •. /~~ Foy -~~ , 7 ~~ ~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR dTHER): ,A A) LOBBYIST DISCLOSURE: (Required) Q ~~--- B) PR-NCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~~%'V ~-- 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 pending 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": ~: Are you ioppvmg on a penar!ng application for a Development Agreement with the Citv ~ application for change of zoning map designation or change 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. . a rn ~ ~~ J ~ N v 20.M-. u aza~a N d¢Z ~~o m V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL1DENTIFICATION: ~Producred D L~~jo2io-.55l0~~3'/J~-C~ ~Produ~d~` /'1,.~0~~'~l7 ' /~-a95--~ Form of Identification Form of Identification ^ Personally known (Lobbyist) SIGNATURE AND STAMP OF NOTARY: of Florida, County of Miami-Dade t to and subscribe be~fo~e me 2 ,dav of ,~`~ , 2Q10 gnature~if Public~otary -State of Florida ~tarization~of Lobbyist's signature ^ Personally known (Pr ISABELSATCFIf:II a~ is 't: M EX~P RES: Apri#103, 201391 Q<- Bonded 7hm Notary Public Underwriters ~~ , ate. State of Florida, County o Sworn and subscri d be re me This ~,~d f 1 L~ Signature f Public a -State of Florida Notariza ion of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MC~ Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration orm 2010.doc Paid Revised OSkHB/2010 I do solemnly swear that all of the foregoi a are true and correct and that I have read or am familiar with the provisions contained in Section 2-482~p mi Beach City Code an qui~ements. m /ViiAMIBEACH City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 CiyClerk@miamibeachfl.gov Acknowledgement of fines/suspension from lobbying for failure to comply with City of Miami Beach lobbying .Laws LOBBYIST NAME: I understand that no later than October 1st of each year, lobbyists subject to lobbyist registration requirements shall submit to the city clerk a signed statement under oath listing all lobbying expenditures, ds well as compensation received, for the preceding calendar year with regard to the specific issue on which the lobbyist has been engaged to, lobby. A statement shall be filed even if there have been no expenditures or compensation during the reporting ,period. The statement shall list, in detail, each expenditure by category, including food and beverage, entertainment, research, communication, media advertising, publications, travel, lodging and .special events... FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE "DISCLOSURE REPORT WILL RESULT IN A FINE OF $50.00 PER DAY. ANY :LOBBYIST WHO FAILS TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL AUTOMATICALLY BE SUSPENDED -FROM LOBBYING UNTIL ALL FINES ARE PAID, UNLESS .THE FINE HAS BEEN APPEALED TO THE MIAMI-DADE COUNTY COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to either file the report and/or pay the assessed fines, the Clerk shall notify the Miami-Dade County Commission on Ethics and Public Trust. IN ADDITION, ONCE AN ISSUE 1 HAVE REGISTERED TO LOBBY ON HAS BEEN RESOLVED, I AM REQUIRED TO IMMEDIATELY NOTIFY THE CITY CLERK'S OFFICE OF tO~rBY1ST WITHDRAWAL IN WRITING. gn urn/U~ v ~Q /3 /~ Date: