Harold Rosen - Dr. Magillen g.
City of Miami Beach Office of the City Clerk 2012 MAR 26 ANI 10: 17
1700 Convention center Drive, Miamir Beach, FL 33139
LOBBYIST REGISTRATION FORM S OFF lc.!_
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 foreseeabiy will be heard or reviewed by the city
commission, or a city board or,SonmIttee. The term specifically includes the principal as well as any employee engaged in lobbying
activities. The term"Lobby�ist§" has specific exclusions. Please efier 77nance 2004-=S.
NAME OF198BYIST: (Last) (M
z� (First)
SU93 ESS NAME AND ADDRESS (Numbbr and Street) (City)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
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Pleaseenoiffy.this-�,,Offi4&&il(�V46i�r,,coritadidiff6tiligition,dhanger.,a4d 06 -�6r.eiina Lai ress.-
I. LOBBYIST RETAINED BY:
10n a(
NAME-01F PRINCIPALICLIENT:
BUSINESS NAME AND ADDRES75 (Number and Street) -(State) (Zip Code)
TELEPHONE NUMBER-. FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section It principal Is a Corporation,Partnership or Trust[Section 2482(c)]
• 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:
4—
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Issue to be lobbied(Describe in,detall):
t
Pursuant to Ctty Code Section 2482(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 personnel from 12 months preceding such person's
commencement of service wiih the city to the present date,stating the general nature of the suoject contractual relationship.
See 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
tftie of person to be lobbied
Ulf J
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,tamillial or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who Is
sou hl to be lobbied as Identified on the lobbyist registration form filed.
See 2-482(g)An Financial,Familial or Professional Relationship
FACLER\$ALL\aF0RMS\L0BBY1ST FORMS\LobbyiSL RegisTrafion Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Requited)'
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): �f .
(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 No: Are vou lobbying on a Rresent or Pending bid for goods,a ui ment or services,or on a present or pendinal
\ award for goods.equipment or service?
2) n4EN nt to Miami Beach City Code 2-490 Entitled'Prohibited Campaign Contributions By Lobbyists On Real Estate
pment Issues":
Eyes Are you lobbyina on a Pending application for a Development Agreement with the City or application tar
change of zonino map 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 a not-for-profit corporation or entity without special
f-ENo: sabon or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
all register with the clerk as required by this section but,shall not be required to pay any registration tees. -
€Ye Are vou re resents not-for-profit corporation or entity without special compensation or reimbursement. .
V. 1014ATURE UNDER OATH:
ON F1 UARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TOAE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING EXPENDITUR AS WELL AS COMPENSANON RECEIVEDJN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FJLJW EVEN IF fist AVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
5ignatu of y(st
I do solemnly swear that all of the foregoing, cts are true a correct and that I have read or am familiar with the pro visions contained
in Section 2-482 of the Miami Beach City de and al ap ing requirements.
Signature of Lobbyist:
Signature of PrinclpaVCllent:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Ident'Ificabon
Perso'ly Ivtow Lobbyist) ° Personally known rincipal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida4ofMiami-Dade
ade Sworn t d subscribed fore me s2 Swor d sub This of L�p2t�-i This day NOTARY PUBLIC y- Notary Public State of Florida
Louvaine Beaudry
Signatur orida Signature of Public Nota My Commieaion EE1 ae808
Notarizati �b s 6 Notarization of Princin Expires 12/09/2015
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
AnnualReg fee- Ye '[ No mcntaldi °Date P.ald
I;Lobbyist-Magistratiori`Form received•arid veriffedby:
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City of Miami BBach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeQchfl.gov
CITY CLERK Office CityClerk @miamibeochfl.gov
Tel:305.673.7411 ,Fax:305.673.7254
LOBBYIST NAME: o
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 ensation Form Lobb ist Expenditure and Compensation I Y P P
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 principalI 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 $50.00 a day shall be assessed for all Statement(s)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, 'who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all. fines are paid, unless the fine has been
appealed to the Miami-Dade County Cgcxp8sion on. Ethics and Public Trust.
0
Signature: G= --- a e
F:ICLERI$ALL1aF0RMSIL0BBYIST FORMSUobbyist Registration Form.doc