Jeffrey Bercow/Miami Beach Community Kollel, Inc.
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MIAMI BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
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 "Lobbyistsn has specific exclusions. Please refer to Ordinance 2004-3435.
Bercow
Jeffrey
NAME OF LOBBYIST:
(Last)
(First)
(M.!)
Bercow & Radell, P.A. 200 South Biscayne Blvd., suite 850
BUSINESS NAME AND ADDRESS (Number and Street) (City)
Miami, Florida 33131
(State)
(Zip Code)
(305) 377-6220
TELEPHONE NUMBER:
(305) 377-6222
FAX NUMBER:
jbercow@brzoninglaw.com
EMAlL:
I. LOBBYIST RETAINED BY:
Miami Beach Community Kollel, Inc.
NAME OF PRINOPAl./CUENT:
Miami Beach Community Kollel. Inc.
BUSINESS NAME AND ADDRESS
3767 Chase Avenue
(Number and Street)
Miami Beach
(City)
FL
(State)
33140
(Zip Code)
(305) 532-8991
TELEPHONE NUMBER:
(305) 532-8925
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 BENEFIOARY: Rabbi Yaacov Gross
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Application for certificate of appropriateness for design and demolition to the Design Review Board (ORB).
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Thomas Mooney None
William Carey None
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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 X No: Are YOU lobbyinG on a oresent or DendinG bid for Goods. eGuioment or services. or on a
oresent or oendinG award for Goods. eGuioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Yes X No: Are you lobbyinG on a oendinG aoolication for a Deyelooment AGreement with the City or
aoolication for chanGe of zoninG mao desiGnation or chanGe to the City's Future Land Use
Mao?
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 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 X No: Are you reoresentinG a not-for-orofit cOl'Doration or entity without soecial comoensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPE URES, A ELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE E ED G ~E DAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EX N ES {,IK ON DURING THE
REPORTING PERIOD. :~/ -
I do solemnly swear that all
familiar with the provisions
requirements.
Signature of Lobbyist:
Signature of Principal/CIi
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
VII.
Produced ID Produced ID
Form of Identification lZI;t};::! z //-------- -'Form of Identification
~LObbyist) I ~r.p.::s.onaIlY known ~rinci ~~'" v. MENori'-~~~-~I.
~ tT1 C) "--- .---/ ':~ MY COMMISSION # DO 285215
SIGNATURE AND STAMP OF NOTARyF..g. ~ R '0 -.---- . ~ EXPIRES:January27,2008
~ @ :::s ~ t:; t .. Bonded TIvu Notary PulJlIc UndelWlilers
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g.~.. &. g ~State of Florida, County of Miami-Dade -
8' :::s 0 ~SWOri(~d sUbs.cri ed bef e ei.c l
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s 8 0 (j) S Signature of Public 0 - State of Flo ida
" 0 Q:) N ;:c- Notarization of Principal's sig e
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This 3\51" dayof~ .200(.,
S~~N~Florida
Notarization of Lobbyist's signature
FOR CLERK'S ~E ONLY I"':r-t
Annual Registration fee: - ] Yes [ ] No Amount Paid ~ 6. MCR # 2o-r-r-J.9 Date Paid
Lobbyist Registration Form received and verified b~ 0. ~ Entered By:
F:\CLER\$ALL\MARIA-M\Lobbyist\lOBBYlST fORM OS.doc
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Revised 12/08/04