Neisen Kasdin/Colony Theater Café Inc.
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 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 commiriee. 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.
~AsDIN N~IS~/l~ Q.
NAME OF LOBBYIST: (Last) (First) (M.I)
A kcrmar'1 S'evl-l,:r~l ~ I SC ~'' Ave , aStti ~_ W11awn i . FL 3313
BUSINESS NAME AND ADDRESS (Number and Street (State) (Zip Code)
C3G5 ~ 3?y- S6i9~ (~aS) 371 SaA~' n ~e f.s~+n . k-~Is~.rl A ~ hcr,~~i/~ ~ cG~
TELEPHO NUMBER: FAX NUMBER: EMAIL.
LOBBYIST RETAINED BY:
Go~anv ThPal~er C,.~P Inc
NAME OF PRIN AUCLIENT:
it (,~-I1 Je~~Prsovti AvP~]v ~~~FIo~X' /'Yliolrni YS~r~d, C~ ~313~
BUSINESS NAME AND ADDRESS (Number and treet) (City) (State) (Zip Code)
NUMBER: FAX NUMBER:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Y-'- al r l~ ,Soy ka,
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: '
6rra-Z l o-rl .SEXY
n.SPECIFIC LOBBY ISSUE:
to be
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(g-
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 City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An Financial, Familial or Professional Relationship
~ l~ Gpw-m~.ssiuh ^/~/~.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ` I~f'T~~~' ~ ~!J
B) PRINCIPAL'S DISCLOSURE (OF LOBBYItS-Tt COMPENSATION): L
(Required). ~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes LWNo• Are you lobbvina on a present or pendina bid for aoods eauipment or services, or on a
present or pendina award for aoods eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes LJV No• Are you lobbvina on a pendina application for a Development Agreement with the City or
application for chance 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 LYAVo' Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
.... .. ~.•r.. r.~r. •ST ~~ c A nu vi
of
I do solemnly swear that all of the f ing facts are true and correct an ha have read or am familiar with the
provisions contained in Section 2-48 Miami B ach City Code and rep rting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIF ,Dls- PR C AL IDENTIFICATI
^ Produced ID Produced ID 1 /~~~~ ~`~~~7"~' - l -~ ~~c~ "~
Form of Identification Form of Identification
Personally known (Lobbyist)
^ Personally known (Principal)
VII. SIGNATURE ANf~T~1paP_QF NOTARY:
State of Florida, County of i - ~tAWlad~lis>lMteof
Sworn t subscribEd. QI9r+w4d € F9iMl1d~#
This ~'~ "" day of ~ - O~~a~~a eeisi~ ~~~~
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
~" TO BE COMPLETED B'
Annual Registration fee: [ ]Yes [ ] No Amount Paid
Lobbyist Registration Form received and verified by: _
~:IC:LEf~~L{~ai$YIST~~.obt~y .. ;, ren
~ ~ `
"
~
Stat f Florida, County of Miami-Dade ,
-
Swo p d subscri fore me
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This day o~
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-State of Florida
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Notarization of Principal's signature ~
LERK'S STAFF ONLY ~~,,,,,.
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MCR # Date Paid ~ "~~
-
J~.Q ~ Revised 03/27/2008 ~"'~~
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME:
C ifyClerk@miamibeachfl.gov
--~-C~~
I understand that no later than October 1st of each ~Ceer, 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
2J 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.
~~
Signature: Date:
Ravisad 02104.;2008