Jeffrey Bercow - Michelle Burger �•70 l N e !`'��r a�•an
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
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LOBBYIST REGISTRATION FORM 206 H
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to enco6rage`tf,d pass,jg;e, �efer�tLor
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. I
Bercow Jeffrey
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 374-5300 (305) 377-6222 ibercowCa�brzoninalaw com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
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Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Michelle Burger V 1'e-,Z_ �Y s JOAJ
NAME OF PRINCIPAUCLIENT:
Middle Beach Community Association, Inc. 820 Lakeview Drive Miami Beach Florida 33140
BUSINESS NAME AND ADDRESS (Number and Street) (Cit
(305) 374-5700 y) (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:
II.SPECIFIC LOBBY ISSUE:
Board of Admustment#3696 1Y IV° /q ' y V
Issue to be lobbied(Describe in detail):
III. CITY AGENCIEWINDIVIDUALS 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 relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such
person's commencement of service with the city to the present date,stating the general nature of the subject contractual relationship.
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship(Explain) YES I NO
title of person to be lobbied
Tanning Department and Building Department Staff None X
B, HPB, BOA, City Commission, as necessary* None X
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)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) $ D
B) PRINCIPAL'S DISCLOS�7(OF LOBBYIST COMPENSATION):
(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 X No: Are you lobbvina on a oresent or pending bid for goods eauioment or services or on a present or
pe=award for goods.eauioment 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 lobbvina on a pending application fora Development Agreement with the City or application
f�change of zoning man desianation or change to the City's Future Land Use MapZ
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.
Yes N No:
V. SIGNATURE UNDER OATH:
ON E90RUARY 29 OF 9ACU YEAR, EACH CITY CLgRK A SIGNED STATEMENT UNDER
RECEIVED, CIJY OF MIAMI BEACB
EM THE PREC9DING C EVEN JE THEgE HAVE BEEN No
EXPENDITURES OR C
Signat e o obbyist
I do solemnly swear that all of _ foregoi facts are true and corr t and that I have read or am familiar with the provisions contained
in Section 2-482 of the Mia Bach Cit de and al eporting re uirements.
Signature of Lobbyist:
Signature of Principal/Clie
VI. LOBBYIST IDENTI ICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identificatio
yPersonally known(Lobbyist) Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
MEQz
woa•aolaas toNePlJolZ Lo-ema(Lot)
State of Florida, County of Miami-Dade t3 X08.£Z 4g JOW S3bIIdX3 1''"'s'...... tate of Florida, County of Miami-Dade 3 d 2
Sworn to and subscribed before me f�oP. :�,�� worn and subscribed bef re me (3 3 M
This - -- day of h RfLG ,2014 BzIEBO��#NOISStww00�w d o ,2014 0 PCs,'
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Signature of Public Nota —Stat6 of FI da Signature of P lic Not —State of Florida N
Notarization of Lobbyist's signature Notarization of Prin�al®s signature
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TO BE COMPLETED BY CITY CLERK'S STAFF-ONLY
Annual Registration fee: [ Yes[ ]No Amount Paid$ MCR# 920pt Date Pai
Lobbyist Registration Form received and verified by: N . C04 ' -�
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F:\CLE istrallon Form,doc Revised 04/27/2012
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachf.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME Jeffrey Bercow
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 suspend d from lobbying until all fines are paid, unless the fine has been
appe d to the MiaM,i- de County Commission on Ethics and Public Trust.
Sig re: Date:
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