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Michael W. Larkin - Marc Lehmann & Jean Kim ® �C1 �f City of Miami Beach Office of the City Clerk IDCk1 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.I) Bercow Radell& Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131 (305) 374-5300 (305)377-6222 mlarkin brzoninglaw.com TFI FPHQMF NI IMRFR• FAX NI IMRFR• F nAII Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Marc Lehmann &Jean Kim NAME OF PRINCIPAUCLIENT: 4490 North Jefferson Avenue Miami Beach Florida 33140 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 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,PAK I NCR OR BENEFICrAKY. Please see attatMed EX111151tA. • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST c� II.SPECIFIC LOBBY ISSUE: .� C � Development Approvals and Permitting Issues for 3591 Flamingo Drive m ry i_ Issue to be lobbied(Describe in detail): uL['_ITY AGENIf_IFIgmmnlyini JAI_S TQ RF 1 QRR1F:n- Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whether the lobti' t haantered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months poceding 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 Planning Department and Building Department Staff None X B, DRB, BOA, City Commission,as necessary None X 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 None F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc I IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$475.00 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required)._$475.00 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": Are you lobbying on a present or new ndin0 bid for goads equipment or services or on a present ore ndina 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": [] application chime 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 clerk as required by this section but,shall not be required to pay any registration fees. []Yes Are=represanting a not-for-profit corporation or antely lgithout spacial compgnsation bursemant 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 EXPFNDITURFS OR COMPENSATION DURING THE REPORTING PERIOD_ X Signature of hebbyest 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 ID Form of Identification (+:y: ,. ILERKO clIMPMENon f MY COMMISSION#EE143406 tt/Personally known(Lobbyist) f , II�ERrnar�ap�lp2,2015 (407)398-0153 Florid U ' com VII. SIGNATURE AND STAMP O ,':�Y°''• CRIS11NA D.GONZALE1 State of Florida, County f Miami-Dad - State of Florida,County of Miami-Dade ty ;*: x MY COMMISSION ti DD 960888 Sworn to and subscribed b ore. a ;.. EXPIRES:March 23,2014 Sworn and subscribed before me F� Bonded Thru Notary Public Underwriters This 2 day of This `Z -�day of 20 p.�,�,��� Signature of Public Nota[y— tate f Flori Signature of Public Notary—State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature / TO BE COMPLETED BY CITY CLERK'S STAFF Z7 Annual Registration fee: [ ]Yes[✓ ]No Amount Paid$ MCR#,�� 4 Date Pal Lobbyist Registration Form received and verified by: ' F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc on». oc Revised MIAMIBEACHCity 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: Michael W. Larkin 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. Pursuant to Section 2-485 (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 after the 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. i 2 7 d� Signature: D e: FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc