Amy Perry/Mt. Sinai Medical Center
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 defined in any manner in this section, 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.
NAME OF LOBBYIST: (Last) (First) (M.I)
Mount Sinai Medical Center 4300 Alton Road Miami Beach FL 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 674-2520 (305) 674-2007 Amy-perrCalmsmc.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
Mount Sinai Medical Center
NAME OF PRINCIPAL/CLIENT:
4300 Alton Road Miami Beach FL 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)674-2121
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:
Mount Sinai -Miami Heart Institute matter
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
1. Planning Board None.
2. City Commission
3. City staff
4. Health Facilities Authority
5. Zoning Board of Adjustment
5. Health Facilities Advisory Board
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $ 0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 0
X Yes 0 No• Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach Citv Code Chanter 2, Article VII, Division 5
Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camnaian Contributions By Lobbyists On Procurement Issues":
0 Yes X No: Are you lobbvina on a present or cendina bid for goods, eauipment or services, or on a present
or pending award for goods, eauipment or service?
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chanter 2, Article VII Division 5
thereof Entitled "Camnaian Finance Reform", Via The Addition Of Code Section 2-490 Entitled °Prohibited
Camnaian Contributions By Lobbyists On Real Estate Develoament Issues":
0 Yes X No: Are you lobbvina on a cendina application for a Development Agreement with the Citv or
application for chance of zoning map designation or change to the Citv's Future Land Use Map?
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 EXPENDITURES, AS WELL AS COMPENSATION RECEIVED,
IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED
EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD.
Signature f bbyist
I do solemnly swear that all of the foregoing facts are true an co ct and that I e read or
am familiar with the provisions contained in Section 2-482 of the Miami Beach City,Code and all
reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: l,J /
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID
Form of Identification
Produced ID =~ '~ '~
Form of Identification =?
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tonally known (Principal) ~
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State of Florida, County of Miami-Dade ~ °z ~
Sworn and. subscrib b ore me
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This day of , 20~ ~_
~~"'"'rt"'~~ ~sonally known (Lobbyist)
~ ~ ~ VII. SIGNATURE AND STAMP OF NOTARY:
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~ > ~ ~ State of Florida, County of Miami-Dade
~ ~ ~ Sworn to an~ subscribe bef re me
~ g This 1 I ~ a of , 200
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Signature of Public Notary -State of Florida
Signature of Public Notary -State of Florida
notar~zat~on of
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FOR CLE S USE ONLY
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Annual Registration fee: [ ]Yes [ ] No Amount Paid v MCR 1J ~ a e Paid ~~
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBBYIST\LOBBYIST FORM 04
~ First Revision - 05-17-02