Mitchell W. Berger - Bergeron Land Development, Inc. GGG
v
MIAMI
City of Miami Beach Office of the City Clerk 2013 DEC 18 AM 9: 5 1
1700 Convention Center Drive, Miami Beach, FL 331390 i-p,,-
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"h s specific exclusions. Please refer to Or ' ance 2004-3435.
NAME OF LOBBYIST: (L s (First) (M.I) _
rr f tV 3S0 67.
SI S NAME AND DRESS (Nurp6er and Street) (City) (State) (Zip C e)
914�1 ,F-5-el-:5-�3_--_021 0--->3a; aA29212�b
TELEPHONE NUMBER: FAX NUMBER: E
Please notify�th)s o f your cont6dt-znformafion changes:address,:phone,or e-mail.address,
L BBYIST RETAINED BY:
10 7�� Dale
N ME F RIN291229-
B INE NAME D ADDRESS (Numb nd Street) (Cit (State) 0on ode)
�•496- s •• /�
TELEP ONE NUMBER: FAX NU B R:(Optional) EMAIL:(
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: J�{lfq�a'�1��`
• IDENTIFY ALL PERSONS HO WING RECTLY OR IND!J�ECT A 5°o OR MORE OWNERSHIP 1114TER T IN UCH C O TION,
PARTNERSHIP OR TRUST: //!/ Sr.
u:P CIFIC LO_.BY I Six:
Issue to be lobbied(Describe in detail):
Ill. �o BE EMBED:
C
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 eneral nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of gWrs on to be lobbied
Pursuant to City Code Section 2-482(8)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 Any Financial,Familial or Professional Relationship
F:ICLERI$ALL1aF0RMSIL0BBYIST FORMS\Lobbyist Registration Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) Alw ,06,:� -G 6
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): R .
(REQUIRED). 'L (4 -�r -
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 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 Section 2-490 Entitled'Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes No: Are you lobbying on a pendinq application for a Development Agreement with the Citv 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.
_YeXNo: Are you representing/not-for-profit corporation or entitv without special compensation or reimbursement.
V. SIGNATURE UNDER OATH
ON FEBRUARY 28 OF EAC YEAR EACH LOBBYIST SHA L BMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING XPENDITURES AS WELL ASCOMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMEN SHAM BE FILED E IF THERE HAVE BEEN NO EXP MDITURES OR
COMPENSATION DURINGfTHFi REPORTING PERIO .
nature of r bbyist
I do solemn) swear tha all f t fore of fac true corn ct nd that I have r d or m familiar
y g g a wi the p ovisions contained
in Section 2-482 of the M'am a Cit o e nd a 16 1 re 're ents.
Signature of Lobbyist:
Signature of Principal/Client:
Vl. LOBBYIST IDENTIFI ATION• 7roduoe�11),CIP L IDE 11FICA ON:
_Produced ID PForm f Ide tification '=J`Form of Identification
Personally known( yist _Personally known(Principal)
NN��QRILITEp
VII. SIGNATURE AND STAMP OF NOTARY: `���• ..Goes..20 F.
State of Florida,County of Miami-Dade State of Florida,County ofgiargi�O�A 0069,;
Sworn t subScribed beforq me Sworn and subscribed befidwe
This_ Y 'day _ This _day of __z=,20
RITA SELLERS EE 054132
r� 99••:�' QQ�
Il ff 867553 .• �����•
(;;i of Public W-
Notarization toltaH81Oenuary 22,2017 Signature of Public Notary—State of T",.
of Lo &m yPW*UnderwtlWv Notarization of Principal's signature
fill p+1 O V����'
TO BE COMPLETED j3y CITY CLERK'S STAF,F ONLY
Annual.Registratlon4fee:j[ ]Yes[',�,aUo Amount3Peid$' - MCR?# Dafe:Pald
Lobbyist.Regtstra F tlon m and erfled=Eoelved Y
fF�CEER`$AL'L\aFORMS\LOBSYIST.FORMS\L`obbylst AnnuallRegistration ForrhAoc Revised,))/;lti%2013
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
I
,MIAMIBEACH
2013 DEC 18 All 9: 51
City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfi.gov
CITY CLERK Office i ' i_.I,�-1 I'� J 1 C
Rofoel E.Gronado,City Clerk CityClerk @miami6eachfl.9ov
Tel:305.673.7411 ,Fox:305.673.7254
LOBBYIST NAME: #ItlrAell 4 •
I understand that no later than February 25 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.
'l) 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 not fy any lobbyist(or principal)who
Balls to timely file a Statement and In addition to any other penalties which Irvoay be
Imposed as provided In Section 2-485.1.a fine of$5 0.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shell notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist,who falls to file the required Statement by April S®,shall be automatically
suspended ftxmT19bbyIn9 until all fines are paid, unless the fine has been appealed to
the M mi- ade C unity Commission on Ethics and Public Trust,
'g nature Date
FACLERI$ALWFORMSILOBBYIST FORMS1Lobbyist Registration Form.doc
Miscellaneous Cash Receipt
CITY OF MIAMI BEACH
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(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
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