Harold Rosen/SMG/~ _ ~
City of Miami Beach Office of the City Clerk ~ o
1700 Convention Center Drive, Miami Beach, FL 33139 c °,~ ~
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LOBBYIST REGISTRATION FORM t- ~ '~}
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, drat ~odif'c~atr'on of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Managefaor aaa~~~YYY...,,,city b or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-m ~ ess g~n~such
action, decision or recommendation that foreseeaby will be heard or reviewed by the city commission, or a city board or rn ee. Th erm
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific-eoccl~iins. rase
nfar to Ordlnanee 20043435.
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NAME OF LOBBYIST (Last) (F~rst)
~~
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NAME ANI
(Number and
1• "`',,L~O~BBYIST RETAINED BY:
~~~--
_' NAME OF PRINCIPAUCLIENT:
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
'• NAME OyF~CH~IEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
n.SPECIFIC LOBBY ISSUE:
- '
Issue to be lobbied (Describe in detai
ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:. (Pursuant to City Code Section 2-482(8)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any Citg personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) Ir>clude a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
'(Yl~~ 1~lYKl ~ ,~ ~
et) (Gty) (State)
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(Zip
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A).~•QBBYIST DISCLOSURE~tequired _
B) PRINCIPAL'S DISCLOSURE (OF, LOBBYIST COMPENSA71'6N~~ ~~~ ` ~i- ~-~~~y ~~
(Required). __ ~~ (~ A~ A y7` ~~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
~I Yes ^ No• Are you lobbvin4 on a oresent or pending bid for aoods eQUiament or services or on a
present or pending award for aoods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~NO' Are you lobbving on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the Citv's Future Land Use
Map?
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 snot-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 No: Are ou re resentin a not-for- rofit cor oration or enti without s ecial corn ensation or
reimbursement..
V. SIGNATURE UNDER OATH:
.-
S' t of Lobbyist
J 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 Mi mi'Bea~ de and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: ~~ ~~
VI. LOBBYIST IDENTIFICATIONL:_ PRINCIPAL IDENTIFICATION:
^ .Produced ID ^ Produced ID
,_,,/ Form of Identification Form of Identification
L-~J Personally known (Lobbyist) Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
- State of Florida, County of Miami-Dade State of Florida, Coualsy.ol;A4i~7~.l;~~i
Sworn and subscribed before me Swor and subscr~ed bef r`A~l~IEtA CAhIC~"~O""""'
Th' ~ day of ~g,~, 2008 This day of ~ , ~~ DD074~ i
Signature of P o yaf lorida Signature of Publi~.No be e
Notaii f L t s urn Notarization of Principal's signature ....••«'°"'"`
• /1MO~ COMPLETED BY CITY CLERK'S STAFF ONLY
Annual w~tsr.••(••'~'Y~s J No Amount Paid S MCR # Date Paid
Lobbyis~• egistration Form received and verified by:
F:\CLER\HATL\Form; ~LObbyi:;t itegs-a:x ;a,-.n Fn~-;,,.drr. Ravicnii nQ/77~7nn~
4
~ City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.gov
CITY CLERK Office CiiyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: _ `ri~rP,C~~ ~,C~~ '1
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of-.the Miami Beach City Code, with.. the City. Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and For code violation evaluation..
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signatur Da
Revised 0?f0~?I2006