Jeffrey Bercow/Mount Sinai Medical Centerr~
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.
Bercow Jeffrey
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow & Radell. PA 200 S. Biscayne Boulevard. Suite 850 Miami Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 377-6220 (305) 377-6222 ibercowCa~brzoninglaw.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/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) $ 490 per hour
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 490 per hour
~ Yes X No• Are you reuresentina anot-for-urofit corporation or entity without special compensation or
reimbursement Pursuant to Ordinance No 2004-3435
1) Pursuant to Ordinance No 2003-3393 Amending Miami Beach City Code Chapter 2, Article VII, Division 5
Thereof Entitled "Campaign Finance Reform" ~a The Addition Of Code Section 2-488 Entitled "Prohibited
Campaign Contributions By Lobbvists On Procurement Issues":
0 Yes X No• Are you lobbvina on a uresent or pending bid for goods eauioment or services or on a present
or ~endina award for goods, eauioment or service?
2) Pursuant to Ordinance No 2003-3395 Amending Miami Beach City 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 Lobbvists On Real Estate Development Issues":
D Yes X No• Are you lobbvina on a pending application for a Develoument Agreement with the City or
auulication for ~hanae of zoning man designation or chance to the Citv's Future Land Use Mau?
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL
STATEMENT UNDER OATH, LISTING LOBBYING EXPEND
IN THE CTTY OF MIAMI BEACH FOR THE PRECEDING LI
EVEN IF THERE HAVE BEEN NO EXPENDITURES OR Mf,~
of Lobbyist
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I do solemnly swear that all of the~f~oj~regc
am familiar with the provisio/~~~1 ned
reporting requirements. / /
Signature of Lobbyist:
are-frue and
n 2-482 of tF
AS
Signature of Principal/Client: ~/ ~/~
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICA
^ Produced ID
Form of Identification
flf CLERK A SIGNED
COMPENSATION RECEIVED,
~~NT ALL BE FILED
~H£ RTING PERIOD.
and that I have read or
i Beach City Code and all
^ Produced ID ~~'""`~.~=
V• ,:
Form of Identification ~''
personally known (Principal) ~
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~y~~
a~~
State of Florida, County of Miami-Dade ~ ~ ~ ~
Sworn anal subscribed efore me ~ g
This day of 007
~~
Signature of Public Notary -State of Florida
personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed b fore me
This 11'x- day of ~k~ 20dh
Signature of Public Notary -State of Florida
Notarization of Lobb fist's si nature Notarization of Princi al's si nature
FOR CLERK'S USE ONLY //~
Annual Registration fee: ]Yes [ ] No Amount Paid ~ MCR # ! J Date Paid
Lobbyist Registration Form received and verified by:
Revised 02/10/04 F: CLER\ALL\MARIA-M\LO IST\LOBBYIST FORM 04
~ First Revision - 05-17-02