Michael Larkin - Russell Galbut M 1 A;NA I B EAC H
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.
Larkin Michael W.
NAME OF LOBBYIST: (Last) (First) (M.1)
Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 374-5300 (305) 377-6222 mlarkin(@brzoninglaw.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:
Russell Galbut
NAME OF PRINCIPALICLIENT:
Shelborne_Associates, GP 2200 Biscayne Blvd. Miami Florida 33137
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 573-4127 (305) 573-8489 rgalbut(LDcrescentheights.com
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:
ii.SPECIFIC LOBBY ISSUE:
Developmental Board Approvals for Shelborne Hotel — 1801 Collins Avenue
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(a)(4) Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Commission, Planning Staff, Development Boards None
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the eKt��t)of(�ny�b�r' ih� fiahtlal,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
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required)$445.00
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(Required). $445.00
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":
❑Yes N No: Are you lobbvina on a present or oendina 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[, Now Are you lobbying on a pending application for a Development Agreement with the City or application
f4.Y change of zoning map desianation 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 N No: Are you representina a not-for-profit corooration 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 PERIOD.
Signature of 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.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced IDS:
Form of IIdentificalio Form of %4
a<5-o
/Personally known (Lobbyist) Personally known a 3 m
z A3 Xc
(Principal)VII. � SIGNATURE AND STAMP OF N o o u�
NOTARY: Q N o N 0.State of Florida, County of Miami-DaR State of Florida, County of Miami-Dade A a.
Sworn nd subscrib b for me o SworG?V subscri d before me CL
ay of� 2 -n T ' �'v day of 2012
m Si nature of P blic otary—State oS nzhure of ublic otary—State of Florida
Notarization of Lobbvist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date id
Lobbyist Registration Form received and verified by:
Il `
® MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive. NAarni Mach, Florida 33139,www.rnian-ibeach0.gov
Cr1YCI.MKOttice CityClerk a iiatnibeachll.gov
Tel: 305.673-7411 , Fax: 305.673.7254
LO B B Y IS T N A M E: Michael W. Larkin
I understand that no later than February 28th of each year, I mast file the following
fonr4 pursuant to Section 2485 of the Man-i 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 0 ffice.of lobbyist withdrawal in writing.
Pursuant to Section 2485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2 .485 . 1 , a fine of $50.00 a day shall be assessed for all Statement(s)
filed afterthe due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami Dade County Commission on Ethics and Public Trust.
Signature: Date:
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