Michael E. Epstein - MESP, Inc. ' Y
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City of Miami Beach Office of the City Clerk
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1700 Convention Center Drive, Miami Beach, FL 33139 I'
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
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (First) (M.I)
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BUSINESS 'NAME AND ADDRESS (NumbeJand Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMA L:
Please notify this office if your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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B ES NA AND DRESS (Num r d tr ) ) (State) (Zip Code)
TELEPHONE NUMB R: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ` ; ,AA_ 1 cpw_ivA
yvt • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II SP ECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. 'CITY' AGENCIES /INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2- 482(g) include
a statement of the extent of any business, Fnancial, 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 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 Name of Individual /Title B) Any 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) N1 11 gt6 MOO
B) PRINCIPAL'S DISCLOSURE (OF LOB YIST COMPENSATION)
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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 ":
❑ Yes VI No: Are you lobbying on a present or pending bid for goods. equipment or services. or on a
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 ":
❑ Yes iyi No: Are you lobbying on a pending 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 a not - 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 IN No: Are you representing a not - for - profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH: ,
ON OCTOBER 1 OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH. LISTING LOBBYING EXPENDITURES. AS WELL AS COMPENSATION
RECEIVED. IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL -
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENS '�.y. URING THE REPORTING
PERIOD.
Signature of Lobbyist ---
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 Be - ch ' • Code and all reporting requirements.
Signature of Lobbyist: /�
Signature of Principal /Clients
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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;:,� Prouced ID C4 0/,••'1/-4// 'C,e,t„ .
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° m • m Sworn to and subscribe before me Sworn an subscribe before me :pi ;
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Fri n � rn This S day of ctJ , 2010 This /l ay of _fi • , 2010 ` , � . m'
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o = 32. Signatu e of ub c otary Signa Cie of Publi Notary 4 '
9 ry -• State of Aida g ry - State of rich F ,.
o 4= b 22 Notarization of Lobbyist' signature Notarization of Principal's signature TIM
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N tMl TO BE COMPLETED BY CITY C RK'S STAFF ONLY
Annual Registration fee: [ ] Yes [ ] No Amount Paid $ " "' MCR # ' 0 7 ' ti - Date Paid I 1 1 S 1
Lobbyist Registration Form received and verified by: 9 %
F: \CLER \$ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc '74,.. c Revised 05/28/2010
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MIAMIBEACH
Cit 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: tM t ci e ( ?WI' ✓l
I understand that no later than February 28th of each year, I must file the
following form, 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 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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Signature: Date:
Revised 09/24/2010 - REP
F: \CLEF' \LOBBYIST \Expenditure & Disclosure Forrn Itr.doc
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic
community