David R. Custin - Waste Pro of Florida, Inc. MIAMIBEACH � e
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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 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.
Custin David R.
NAME OF LOBBYIST: (Last) (First) (M.I)
David R. Custin & Associates, Inc. 6401 SW 113 PL, Miami, FL 33173 -1083
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305 -412 -3772 305 -412 -3773 CustinDR@DavidRCustin.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Waste Pro of Florida, Inc.
NAME OF PRINCIPAL/CLIENT:
Waste Pro of Florida, Inc. 4701 NW 35 Ave. Miami FL 33142
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
954 - 967 -4200 or 305 - 651 -7011
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
John Jennings, CEO
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: John Jennings 73 % , Roarke Capital 11%
['.SPECIFIC LOBBY ISSUE:
Waste hauling services franchise
Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2-482(aX4) Full Name of Individual and Contractual Relationship (Explain) YES NO
title of person to be lobbied
City Manager & administrative staff None
Commissioners Wolfson, Weithorn & Exposito Political campaign consulting services I ✓I
Mayor & all other members of the Commission None
Pursuant to City Code Section 2.482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) Any Financial, Familial or Professional Relationship
Serve as a vendor to Commissioner Wolfson fodabffiliCiltii4t service communications.
za :ft Wd I - 1101 JUL 1 ?n11
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) $ 1 5 5,000 every twelve months (per calendar year)
B) PRINCIP�'§ IJSJI (OF LOBBYIST COMPENSATION)::
(Required). BUJ every twelve months per calendar year)
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 ":
— 1 Yes 7 No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a present or pending
award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues ":
es / No: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation or change to the City'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 a not - 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 Ei No: Are you representing a not - for - profit corporation or entity without special compensation or reimbursement. .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPE TION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT ALL B IF RE E BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIO . f•■
\ Signature of Lobbyist
I do solemnly swear th. all of the fcre• ng «•. are ,• - an « , �. ... that I have read or am familiar with the provisions contained
in Section 2-482 of the ,. ami Bea C• • - and . re•orti • . -ments.
Signature of Lobbyist: - _ .,-
.�,.. - —.—
Si of Principal /Client: / � ,
VI. LOBBYIST IDENTIFICATION: �} PRINCIPAL IDENTIFICATION:
®Produced ID - C 2-30 17 (D(p / ((02 O [} Produced ID FL, i9 i li o nY) 7Z' W 69
Form of Identification Form of Identification
❑ Personally known (Lobbyist) ❑ Personally known (Principal)
���11111 \ ���1111 11111 ISON ��
VII. SIGNATURE AND STAMP OF N aAN 84-4 �ii� ��� p, . O
_NI, GO C' p si .� C • •GOMMIS4 0 •• i
State of Florida, County of Miami-Dade z.-* • k ppri1 u 2 ' y9 State of Florida, County of Mia$ir�pd� ' o �e mber � ' y F • � y �_
Sworn to and subscri• - • before me : z ; '`'A : - o s Sworn subscrib�d .:fore el - ' f, v
This day of I!, 20£1° : m : - T ' ! day o / ,• lb • . ; ?
S i. i ature of Publ . otary - State of Flo•.• .• 4 c e a write, �p -, Sig at - of Public No ary - State of Flor Be •• derv; PR , ��`
Notarization of Lobbyist's signature / C �T � •••• ;0? ∎ ∎� Notanzation of Principal's signature , � j �`I p,` TE
TO BE COMPLETED BY CITY CLERK'S S , FF ?J Y 771111111
/ /
Annual Registration fee: [ ] Yes ( ) No Amount Paid $ fO -- MCR it V0147 � Date Paid / f T
Lobbyist Registration Form received and verified by: I_/ . /
F: \ CLER \BALL \aFORMS \LOBBYIST FORMS\ LobbyistAnnyal Registration Form.doc , ' A-- / Revised 1/11/2011
•
Apr MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: David R. Custin
I understand that no later than February 28th of each year, I must file the following form, 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 and Compensation 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.
July 1, 2011
Signature: Date: