Eileen B. Mehta - Bath Club Condominium Association {.11
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.
MEHTA EILEEN B.
NAME OF LOBBYIST: (Last) (First) (M.1)
Bilzin Sumberg Baena Price&Axelrod LLP, 1450 Brickell Avenue, Suite 2300, Miami, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-350-2380 305-351-2240 emehtaa-bilzin.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
The Residences at the Bath Club Condominium Association Inc. &The Residences at the Bath Club Maintenance Association Inc.
NAME OF PRINCIPAUCLIENT:
c/o Tom Ireland 12000 Biscayne Boulevard, PH 810 Miami FL 33181
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-891-6806 305-895-8241
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust[Section 2-482(c)]
ru
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Tom Ireland, President --d '
00 %fit
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5% OR MORE OWNERSHIP
INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: p, ;'TI
II. SPECIFIC LOBBY ISSUE:
o
Issues related to the use and operation of the Bath Club building and surrounding facitlities and the peridrng 6tFb&al of the
Board of Adjustment decision denial to Bath Club Entertainment. LLC and Collins Avenue Associates, LLC
Issue to be lobbied(Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Sec 2-482(a)(4) Full Name of Individuall and title of B)Contractual Relationship(Explain) YES NO
person to be lobbied
City of Miami Beach, Planning Department Staff and X
Zoning Department Staff
City Attorney and City Commission x
Board of Adjustment x
i
MIAMI 3869422.1 80372/424 64
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER)
A)LOBBYIST DISCLOSURE:(Required) $625/hr
B)PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):(Required). $625/hr
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 4No: 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":
E Yes tiNo: 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..
D Yes 4No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement?
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28T"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:
Tom Ir d
VI. LOBBYl NTIFICATION: PRINCIPAL IDENTl CATION:
Produced ID 1 Produced ID
Form of Identification Form of I
Personally known(Lobbyist) Personally known(Prime "'
P1.
: ..tY :i+
VII.SIGNATURE AND STAMP OF NOTARY: '7 _? ?36453 EXNi;;=-::
State of Florida,County of Miami-Dade State of Florida,County of T �ioi dordaory$crvka,c;r�
Sworn to and subscribed before me Sworn a d Subscribed before me
This day of 20 This day of Se 2013_,
Signature of Public Notary–State of Florida Signature of Public Notary–State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
......_....._—......
FOR CLERK'S USE ONLY '
Annual Registration fee:[]Yes[ ]No Amount Paid MCR#_ Date Paid
Lobbyist Registration Form received and verified by: _
Revised 04127112
MIAMI 3869422.1 80372/42464
I
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATR(DISCLOSE WHETHER HOURLY FLAT
RATE OR OTHER)
A) LOBBYIST DISCLOSURE: (Required) $625/hr
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $625/hr
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�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�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�No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement?
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28T" 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 EV N IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. 2-Z_
ignature of Lobbyist
I do solemnly swear that all of the foregoin facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Mia ,ire q AC-
Indall/reportin quire nt .
Signature of Lobbyist:
Signature of Principal/Client:
Tom Ireland
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ❑ Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) ❑ Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn o and subs ribed bef�e me SPRY PCB MERCED96v9 end subscribed before me
This col'Z day of �� b2 ,20� ��' ��'�c* MY COMMISSMiSEE 0284721ay of ' 20
EXPIRES:November 9,2014
Bonded Thru Budget Notary Services
Signat re of Public Notary—State of Florida Signature of Public Notary—State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLER ' USE ONLY !, C-
Annual Registration fee: []Yes[ ] No Amount Paid MCR# z 7 ate Paid /
Lobbyist Registration Form received and verified by:
Revised 04/27/12
MIAMI 3869422.1 80372/42464
vp
�;� •
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive, Miami Beach,Florida 33139
www.miamibeachfl..yov
LOBBYIST NAME: Eileen B. Mehta
I understand that no later than February 28th of each year, I must file the following forms,
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 Form 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 of each year, 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.
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Si ature: Date:
MIAMI 3869422.1 80372/42464
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