Michael Milberg/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.
Milbero Michael
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) 674-2444 (305) 674-2007 mmilber4@msmc.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
• 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/INDMDUALS 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 reoresentdng anot-for-urofit corporation or entity without suecial comuensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach City Code Chanter 2, Article VII, Division 5
Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled °Prohibited
Camoaion Contributions By Lobbyists On Procurement Issues":
0 Yes X No: Are you lobbying on a uresent or cending bid for goods, eauioment or services, or on a present
or pending award for goods, eauioment or service?
2) Pursuant to Ordinance No. 2003-3395 Amendino Miami Beach Citv Code Chapter 2, Article VII Division 5
thereof Entitled "Campaign Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited
Campaign Contributions By Lobbyists On Real Estate Development Issues"•
D Yes X No: Are you lobbvino on a oendina application for a Development Agreement with the City or
application for change of zoning moo designation or change to the City's Future Land Use MaD?
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 CA DAR YE ATEMENT SHALL BE FILED
EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COM S T O U THE REPORTING PERIOD.
Signatur f Lob yist
I do solemnly swear that all of the foregoing facts are true and correct and that I have 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: ~
VI. LOBBYIST IDENTIFICATION: PRINCIPAL II
s~..,.,..•~F ~ Produced ID
'~•' ~'~'=_ __ ~~ Form of Identification
~'%~ !~.P'ersonally known (Lobbyist)
~ o ; VII. SIGNATURE AND STAMP OF NOTARY:
~m3~
~> ~ ~ State of Florida, County of Miami-Dade
$ ~ Sworn to ar~subscrib b ore me
~ c ~ This ~~day of , 2017
o
i Signature of Public Notary -State of Florida
TION:
Produced ID ,,;~,,,,
sv,."
Form of Identification
~~ Vi
,
wP
ll
k
P
i
i
l i;; .
%°~;;~
ersona
y
nown (
r
nc
pa
)
moo?
~~~~i'
State of Florida, County of Miami-Dade > ~
Sworn a~~.subscri d fore me
~"
d ~ ~ z ~
This
8ay of , 20 ~ o
v~
Signature of Public Notary -State of Florida o
notarization or
FOR CLErR 'S USE ONLr'Y
Annual Registration fee: [ ]Yes [ ] No Amount Paid ~ ~ ~ v MCR # 1`! ~
Lobbyist Registration Form received and verified by: ~
Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBE
Of
I
e Paid ~ ~~ ~
FORM 04
~ First Revision - 05-17-02