Harold Rosen - Miami Beach Owner, LLCG~
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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 eo 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 ctily personnel during the time period of the entire decision-making process on such
action, decision or recc~mmendatton tha# foreseeabfy will be heard or reviewed by the city commission, or a aty board or committee. The term
specifically includes the principal as wed as any employee engaged in ksbbying activities. The term "t.Qbbylsts° has spsclflc exclusions. Please
refer to Ordinance 2004-3435.
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JD ADDRESS (Numb rand Stree
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t. LOBBYIST RETAINED BY:
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~{1AE OF PRINCIPAUI
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(First} (M,j)
(City) (Ste#s) (Zip Code)
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EMAIL:
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EMAIL: (O~tlonal)
out this section if princ#pal is a Corporation, Partnership or Trust
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST fN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
Issue to be lobbied (Describe in detail): .
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III. Cl~'Y. ~i'iGEC~~S11:DIII~U.~~~ ~'p~:$E~ LQIf~Q: Pursuant to City Code Section 2.48218) 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 Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 92 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
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N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
Aj L BYIST DISCLOSURE: {Required]
B) PRINCIPAL'S DISCLOSURE (OF LOB YIST COMP SATs N}:
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Tire following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
4n Procurement Issues":
^-. Yes ~' No: Are you lobbvlno on a preserrt or pendiing bid for goods, eauiDment or services or on a
presen# or pendin~a award for goods. eguipment or service?
2} Pursuant to Miami. Beach City Code 2-4.94 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ®No: Are you lobbyino on a pending application for a Development Agreement with the C
application for chancre of zoning map desianatlon or change to the Ciity,s Future Land Use
M~pa?
3) Pursuant to Miami Beach City Code 2-484 (h} Any person {except those exempt from the definition of
"lobbyis#" as set forth in Section 2-4$1 above}.who only appears as a representative of a not for-profit
carpora~ion or entity without special compensa#ion or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
D Yes ®'No• Are you representing anot-for profit corporation or en#ttv without spgoial compensation or
reimbursement. .
V. 31GNATURE UNOER OATH:
Signature of Lobb '
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Signature of PrincipaUCiient:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
i~[( PersonaNy known (Lobbyist ~~,,~
} LJ'Personally known (Principal)
Vtl. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-bade State of Fiarida, County of Miami-Dade
Th orn to nd sdubsc fbed before m 24~~ - Sworp.,~nd subsc ' cq~~•~I~• `'•~a.......
~_~~ y ~ _ Thj~ 4°~- day of .~nf~:'~ "'URA
Noari of Lr~s~'"sl~y
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`Ann. ..
. Lob .$ a ~s
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Signature of Public
Notarization of Pri
HL'~t~MPLETED BY
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STAFF ONLY
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~~ DD0747842
'i 1/13/2012
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i do solemnly swear that ail of the # regoing facts are true and correct and that {have read ar am familiar with the
provisions contained in Sectio he Miami Beach City Code and all reporting requirements.
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City of Miami Beoch, .1700 Convention Center Drive, Miami Beach, Florida .33139, www.miamibeiachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel:, 305.673.7411 ,Fax: 305.673.7254 .
I understand that no later than Februarw 8th of each ~eca~, I must .file the.
following form, pursuant to Section 2-485 of fhe Miami Beach City Code, with the
City Clerk's Office .for all active lobbying issues.
1 j .Lobbyist Expenditure and Compensation 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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Sign ure: Date:
Revised 09/24/2010 -REP
l":1CLER1LU8BYIST\Expendituri ~ Disclosure l=oan Its°.dr~c
We are commuted to providing ezcelleni public service and safety to oll who live, work,. and play in our vibrant,- tropical, historic
community.