William Goldsmith
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Bach, FL 33139
Emall: cltyclerk@c1.mlami-beach.fl.us
LOBBYIST REGISTRATION FORM
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03 on - 3 AM 9: 33
'~ITY CUJ~K'S OFFICE
(City of Miami Beach, City Code Chapter 2, Division 3, Section 2-481)
o ~ Check Box If an Amendment
NAME OF LOBBYIST:
Bercow
(Last)
Jeffrev
(First)
(M.!.) DATE QUALIFIED AS LOBBYIST
200 S. Biscavne Boulevard. Suite 850
BUSINESS ADDRESS: (Number and Street)
Miami
(City)
Florida
(State)
33131
(Zip Code)
(305) 374-5300
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
EMAIL:
I.
LOBBYIST RETAINED BY:
William Goldsmith
NAME OF PRINCIPAUCLlENT:
1820 W. 25th Street. Sunsellslands #2
BUSINESS ADDRESS: (Number and Street)
Miami Beach
(City)
Florida 33140
(Slate) (Zip Code)
305-949-9049
TELEPHONE NUMBER:
305-948-6478
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section If principal Is a Corporation. Partnership, or Trust [Section 2-482 (ell
? NAME OF CHIEF OFFICER, PARTNER OF BENEFICIARY: N/A
? LIST ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST
IN SUCH CORPORATION, PARTNERSHIP OR TRUST: N/A
II. SPECIFIC LOBBY ISSUE:
Variance Aoollcation for sinale-famllv residence located at 1820 West 25"' Street. Miami Beach Florida 33139
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUAlS TO BE LOBBIED:
A) Full Name of IndlvlduallTltle B) Relationship
Jorae Gomez None
Armando Valdes None
Richard Lorner None
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATRION (DISCLOSE WHETHER
HOURL Y, FLA T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE:
$400.00 Hourlv
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIEST COMPENSATION):
$400.00 HourlY
1) Pursuant to Ordinance No. 2003.3393 Amendina Miami Beach City Code Chaoter 2 Article VII Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Enmled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues";
ment or servic
2) Pursuant to Ordinance No. 2003-3395 Amendlna Miami Beach Citv Code Chaoter 2 Article VII. Division 5
thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-490 Entitled "ProhibRed
Camoaian Contributions Bv Lobbvists On Real Estate Develooment Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1"T OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH FOR THE
PRESEDING CALENDAR YEAR.
Signature of Lobbyist:
Signature of PrincipaVClient:
VI. LOBBYIST IDENTIFICATION:
~produced ID
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NOTARY SEAL
HAMP
NOTARY PUBUC STATE OF FLORIDA
COMMISSION NO. DDl09289
MY COMMISSION EXP. APR. 29,2006
~ .IS Personally Known
VII. SIGNATURE AND STAMP OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn 1P and su~;,'1~id before me
This 13. day of ~' 200t."7
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Signature 0
Print, stamp or type name of Notary Public
FOR CLERK'S USE ONLY
Registration:
~ACCEPTED
[ ] REJECTED
DATE:
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If rejected, state reasll[1:_
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PATAENTRYDATE: 0 ') ,~ENTEREDBY' .