Michael Larkin - Walgreen, Co. � SS�CS
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4. 11 MIAMI BEACH RECEIVE
City of Miami Beach Office of the Cit IIFC 2 I PM 12: 27
1700 Convention Center Drive, Miami Beach, FL
LOBBYIST REGISTRATION FORM T.r S OFFICE
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 dry commission,or a city board or committee. The term
specifically indudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists"has specific exclusions.
Please refer to Ordinance 2004-3435.
Larkin Michael W.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell&Fernandez,PA 200 S.Biscayne Blvd,Suite 850 Miami Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)377-6231 (305)377-62p mlarkinObrzoninglaw.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
L LOBBYIST RETAINED BY:
Walgreen,Co.
NAME OF PRINCIPAL/CUENT: Q J / f
Walareen.Co. !`
!� l V`�hl/y1(y Q f/bicovit 3 Y �C4e'-4 eW(D�,, (,00L
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
gg4.7 - 3 rs-2618. eV'?-3/s-'1640
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: Publicly traded company on NYSE under symbol"WAG"
IL SPECIFIC LOBBY ISSUE:
Development approvals and permitting issues for property located at 7340 Collins Avenue.
Issue to be lobbied(Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED
Pursuant to City Code Section 2-482(a)(4)include the commissioner of personnel sought to be lobbied,and whether the lobbyist
has entered into 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 2482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Planning Department and Building Department None X
Staff
HPB,DRB,BOA,City Commission,as necessary* None X
Pursuant to City Code Section 2-482(g)Every registrant shall be required to slate 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
None.
*Unless an Issue is legislative in nature,HPB,DRB,BOA,&City Commission members are not lobbied outside of a public hearing setting.
41
a
0.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE(Required) $435.00
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):(Required). $435.00
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":
0 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 goods.equipment 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 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 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 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 Berk as required by this section but,shall not be required to pay any registration fees..
O Yes X 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 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
Signature of bbyist
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 report r uirements.
Signature of Lobbyist: /
Signature of Principal/Client: c.1h.(_
VI. LOBBYIST IDENTIFICATION: E _ PRINCIPAL IDENTIFICATION:
0 Produced ID o N 0 Produced ID
Form of Identification 0°r _ Form of Identification
Er Personally known(Lobbyist) z c 0 0 Personally known(Principal)
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VII. SIGNATURE AND STAMP OF NOTAI °
2 I�q
ill 142Q/S: Lc_/z c?_ OFFICIAL SEAL
State of Florida,County of Miami-Dade m State of Florida,County of Miami ode [ABBY D ANDERSON
Sworn to and subscribed before me ;; '` ', Sworn and subsai'-d before me
,-
•-- This(o I— day of�� -n 0/I NOTARY PUBLIC,STATE OF ILLINOIS
This 9-�. day of'1>eca...\�.,20<< _°- -�-: �, �" MY COMMISSION EXPIRES 07/22/2012
Signature of Public Notary—*ate o lorid Signature of Public Notary-State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
Annual Registration fee: [ ]Yes No Amount Palo CLERK'S USE N RO LY Date Paid I i\ -\
Lobbyist Registration Form received and verified by: ,-S c�a36t1\Entered By:ZS Pt' P�v\f\
By
Revised 1/11/2011
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139 wwv miamibeochfL.yov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel:305 673.741 1 ,Fax 305 673.7254
LOBBYIST NAME: /t1( 4 % ( 6d- Z-qr'k-tAt
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.
yv,
'2/6 /
Signature Date.