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Michael Larkin/Walgreen Co. City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM E.:~ ~i ~~~,. UV ~~ ,a~ 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 committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The teen "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. Larkin Michael W. NAME OF LOBBYIST: (Last) (First) (M.I) Bercow, Radell & Fernandez 200 S. Biscayne Blvd., Suite 850 Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 377-6231 (305) 377-6222 MLarkin@brzoninalaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Walgreen Co. NAME OF PRINCIPAL/CLIENT: c/o Seth Gadinskv 1680 Michigan Avenue, Suite 1001 Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 276-2387 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: Publicly traded on the NYSE under the symbol WAG. • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Publicly traded on the NYSE under the symbol WAG. II. SPECIFIC LOBBY ISSUE: Redevelopment of the property located at 1400 Collins Avenue (HPB/BOA) 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 Planning and Zoning Department Staff, HPB, BOA, City Commission None tt ~ ~ : ~ ~ ~ ~z ~nr ~aa~ * Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside of a public hearing setting. ~" IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, ~fLAT RATE OR OTHERf .. A) LOBBYIST DISCLOSURE: (Required) $375.00 pQr hour B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $375.00 per hour 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 X No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a present or pending award for goodsggylpment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes X No: Are you lobbying on a pending aRplication for a Development Agreement with the City or application for change of zoning~a es~gnation or change to the Citv's Future Land Use Man? 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 anot-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 X No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ 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 CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. ~ Signature 6f Lobbyist 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. ~ 1 Signature of Lobbyist: ~ (~' Signature of Principal/Client: VI. LOBBYIST IDENTIFICATIO P NCIPAL IDENTIFICATION: Produced ID Produced ID ~~ - ~, o Form of Identification Form of Identification J z°_ ;- a ``^^ ~ 4/ J ~ Personall known Lobb Est Personally known Princi al "' w J ~ ~ W ~ ~~ a ~ VII. SIGNATURE AND STAMP OF NOTARY: a x -~ ^ -..R: ttpp Q .63 G ~ ~ ,~ ~ ;~= O ~ State of Florida, County of Miami-Dade ~LL1aOkS I.iA K.E State of Fier-ida; County of ~4+aff-i-B~ncFe ,Q ` W .~. ~ V 2 v W m o -T' `'" O II r X ~ Sworn to a subscrib d efor me This P o 20~ Sworn and subscribed before me i ~^ ~' - Q ~'^ LL Z ~ ~ ~ y g This day of mfl , 20 u. ~ ~ S o~ ~ rat ~' `~ ©~PD ao O Z g ~ Sign ure of u c otary -State of Florida Signature of ub ' Notary -State of Florida ar. ~` No rizatio Lobbyist's signature Notarization of Principal's signature FOR CLERK'S USE ONLY Annual Registration fee: [ ]Yes [~No Amount Paid ~.5- MM~CR # a0~' Date Paid ~ o~ Lobbyist Registration Form received/and verified by: ~~~~1 Entered By: F:\CLER\jALL\MARIA-M\LObbyist\LOBBYISTfORM OS.da Revised 12/08/04 _`~ City of Menmi Beath, i 7rJt? Convertian Cerster Drive, Miami Beach. Floric~o 33l 34, www.miomibeachfl.gov C1iY CI~FK Ci~fice CxtyClerk~miamibeac~~.gov TeE: 3Q5.673.7d1 t ,Fax: 3DS.b73.7254 toaB~nsT t~~1AME: ~~ c ~e,.~ Lar k i c~ I understand that no later than October 1st of each Rear, 1 must file the following forms, pursuant to Section 2-4$5 of ~e 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 an a timely basis will resu{t in my name being transmitted to the Miami-Dade County Commission on Ethics and for code violation eva{uation. In addition, once an issue I have reg'sstered to lobby on has been resolved, 1 am required to immediately notify the City Clerk`s C>ffice of lobbyist withdrawal in writing. ~ ~~3 I D~ ' Signature: Date: ;~~~. -. ~,~. ~ - _e-