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Jack Luft - 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 acton, 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 20043435. NAME OF LOBBYIST: (Last) (First) (M.I) Luft Consultino 1717 Windward Way Sanibel Island Florida 33957 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (239) 395-2215 (239) 395-1787 illuftCa earthlink.net TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Mount Sinai Medial 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) $ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ , ^ Yes X No• Are you representing anot-for-profit corporation or entity without special compensation or reimbursement Pursuant to Ordinance No 2004-3435 w o it lL N 0 ~ ~~I `-' _.~~ a ~ ~ o J ~ ~U n ccT ~( Z m G w d ~t S ~'Q.. ~ 1) Pursuant to Ordinance No. 2003-3393 Amending Miami Beach Citv Code Chapter 2 Article VII Division 5 Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited Campaion Contributions By Lobbyists On Procurement Issues"• ^ Yes X No: Are you lobbvina on a present or pending bid for goods eguipment or services r on a present or pending award for goods equipment or service? 2) Pursuant to Ordinance No. 2003-3395 Amending Miami Beach Citv Code Chanter 2 Article VII Division 5 thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-490 Entitled "Prohibited Campolan Contributions By Lobbvists On Real Estate Development Issues"• ^Yes X No• Are you lobbvina on a cending 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 i5T OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CM CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALE~~~'P' i'VEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMP N DUI~NG THE REPORTING PERIOD. I do solemnly swear that all of the foregoing am familiar with the provisions tained 'n reporting requirements. Signature of Lobbyist: Signature of Principal/CI ent: ~` VI. LOBBYIST IDE CATION: PRINCIPAI ^ Produced ID __ Form of Identification personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn d subscrib before me~ This ,- Sig of Florida -State of Florida FOR CLERK'S USE ONLY Annual Registration f~(J] Yes [ ] No Amount Paid # J Date Paid ~~ Lobbyist Registration Form received and verified by: Revised 02/10/04 F: CLE LL\MARIA-M\LOBBYIST\LOBBYIST FORM 04 ar~true and correct and that I have read or r~ 482 of the Miami Beach City Code and all IDENTIFICATION: ^ Produced ID Form of Identification Personally known (Principal) State of Florida, County of Miami-Dade Swom a subscri before me This day 2p~~' 0 u. N ~ ~~ N s ~~~~ a~ ~° >a~T~ Z~~~ m ~o .~ ~ First Revision - 05-17-02