Charles H. Benson - Yossi Lipkin /"V�J11/"11//\v/1d BEACH r co //)All
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 o
modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the Cit)
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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BU NESS N{{,,A,,ME AND AD ESS (Numberr` ncd Street) (Citty),, (State)
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TELEPHONE NUMBER: FAX NUMBER `' 1 1' 1
EMAIL:
Pisase.notify this office if your contact information changes:address, phone, or a-rnaii address.
1. LOBBYIST RETAINED BY:
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NAME OF PRINCI UCLIENT:
BJJSINESS NAME AND R (Number and rest) (City) (State)
(Zip:Co e)
TELEPHONE NUMBER: FAX NUM R: (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.;
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• 'IDENTIFY ALL PE SONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTER ST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: S p v / Cb(OA Mat( Y O 11 10
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(oar nom, Ir1�1U �ut`�I` SaV
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issue to be lobbied(Describe detail): ( ��
n l. ; ►G NCIE 7JNDIVIDLALS D,BEfLOB$`IED: f� . 139
Pursuant to City Code Section 2-482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or
commencement of service with the ci to the resent date,statin the eneral nature of Personnel
he subject contractual relatonshi mg such person's
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
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Pursuant to City Code Section 2-482191 Every registrant shall be required to state the,wtt0 y business,financial familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety,wlffi an curre 4 tW
sought to be lobbied as identified on the lobs ist re istration form filed. y �nEl ��wUj ersonnel who is
Sec 2462LqLLny 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) $1,000.00 FLAT RATE
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $1,000.00 FLAT RATE
(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 Z 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 t] 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 ®No: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th 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 COMPENSATION DURING THE REPORTING
PERIOD. 0
Signature of Lobbyist
Charles H. Benson
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- of e i Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: x .
Yoss Lipkin
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification
❑ Personally known(Lobbyist) t°' Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY: ,o"'yP�.,�
�! .yeG, adriana Mendes
�_� •��CAM1'�SSION�EE015692
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dad : :;
Sworn to and subscribed before me Sworn and subscribed before me %,,�'.r o�c� EXPIRES:AUG.09,2014
This day of , 2010 This dav"f 201
�rn�"` WWW.AARONNOTARY.com
Signature of Public Notary-State of Florida SignatW6 of Public N -:-State of Florida
Notarization of Lobbyist's signature Notar ation of Principal's signature
TO BE COMPLETED BY Cl CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ D — MCR# Date Paid
Lobbyist Registration Form received and verified by: W 7) —A— q
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc dtevised 05/05/2010
MIAMBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME:
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.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2-485. 1 , a fine of $50.00 a day shall be assessed for all Statement(s)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade unty Commission on Ethics and Public Trust.
Signature: �`U Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc