Jorge Kuperman - Doug Bangle _~
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City of Miami Beach Office of the City Clerk _
1700 Convention Center [)hvo' Miami Beaoh, FL 33139
LOBBYIST REGISTRATION FORM
� Lobbyist means all persons employed or mta|nad. whether paid or ncu, by o principal who seeks to encourage the paooage, defeat or
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modification of any onumanue, reen|uhnn, action or decision of any commissioner; any acmon, domsion, 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
� em|e decision-making pmuaoa on such uomon, den|o|nn or recommendation that nonaaeeau|vwill be heard or mwawad by the city
oummioaion, or city board or committee. The wvnn specifically mdudoo the nnnnina| as well as any employee engaged in lobbying
aouvmoo. The term"Lobbyioto" has specific exclusions. Please refer»u Ordinance ouw-n43m.
xupsRMAw JORGE S.
NAME OF LOBBYIST: (Last) (First) (M.1)
JaK ARCHITECTURAL GROUP 1oro/RALDAAVE CORAL GABLES FIL 33134
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-44e'1986 rro'ooe'zoom ].xupo,man00omammtectura|omup.onm
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
|. LOBBYIST RETAINED BY:
DOUG BANGLE
NAME OF PRINCIPAL/CLIENT:
RACHEL'S RESTAURANT&CABARET 621 WASHINGTON AVENUE MIAMI BEACH FIL 33134
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: 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:
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
AmARcV|TsoT OF RECORD WILL SPEAK TO Puww|wo BOARD IN AmTATuo REPORT MATTER
x.SPECUFUC LOBBY ISSUE.
Issue to be lobbied(Describe in detail):
III.CITY AG EN CUES/IN DUVUDUALS TO BE LOBBIED:
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 ,o|^mmnsmp (paid or unpaid) with said city commissioner v, personnel from 12 months pmoouino such person's
general commencement of service with the city to the present date,stating the nature of the subject contractual relationship.Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Pursuant mm City Code Section Every registrant shall he required u,state the extent or any business,financial,familial o,professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought tpmw lobbied as identified on the lobbyist registration form filed.
-Sec 2-482(g)Any Financial,Familial or Professional Relationship
Jul
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)HOURLY
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED).$180 PER HOUR---- -- —
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 X_No: Are you lobbvinq 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes X No: Are you lobbvinq on a pendinq 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 Section 2-482(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.
YesX No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 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 P&EjKD EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
---- — — --------------------
-----------
Si a of Lo ist
I do solemnly swear that all of the reg ng facts are true and corre and that I have read or am familiar with the provisions contained
in Section 2-482 of the Mia. each Ci Co a and all reporting req ' ements.
Signature of Lobbyist: __ __
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATI N: PRINCIPAL IDENTIFICATION:
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Form of Identilgat a �noary 16 :: o Form of Identi kC01
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VII. SIGNATURE AND STAMP OF �99 ��O
N� . �. 2,• a. w _
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State of Florida, County of Miami-Dade s�"Il/19 STATE� � '�` State of Florida, County of M r °°d �36�
,o °�}, dedihru Q�
Sworn to and subscribe before me Sworn a d subscrib before t7 i�••bVicUnde�+00*Q.o�
This _ 2d day of _ 2012 This day of STgTE
Signature of Public Notary-State of Florida 0gature of Public No ary-State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED PY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$— _ MCR#_ _—__— Date Pa'
Lobbyist Registration Form received and verified by:_--_—_--
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
listration Form.doc Revised 04/27/2012
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk@miamibeachfi.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: JORGE S.KUPERMAN
I understand that no later than February 28 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, or I am no
longer lobbying on that issue or for that principal, 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 County Commission on Ethics and Public Trust.
Signature.�� Date:
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Forwevised 5-30-2012.doc