Chad E. Widup - Bergeron Land Development, Inc. MIAMI BEACH
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.
W I�Ve SEA( > F.
NAME OF LOBBYIST: (Last) (First) (M.I)
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B`USIN&SS NAM AND ADDRESS (N X ber and Sir et) (City) (State) (Zip Code)
If6V-1�0c'-:0 73
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TELEPHONE NUMBER: FAX NUMBER: E AIL:
P.leasehotify th'is,o ce�f y -irifottriatiom chanaes.,arddress,phone, or,e-mail_aaltlress _
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I. LOBBYIST RETAINED BY:
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NAME P INCIPAUCLIENT:
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BU QIES N FEND 50 (Number an Stre t) ity (State) • (Zi Code)
TELEPHONE NUMBER: U FAX NUMBER:(Optional) EMAIL ptional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
&7/d• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: A.& Sr•
• IDENTIFY ALL PERSONS HO ING, IRECTLY OR INDIRECTL A 5/ R MORE OWNERSHIP TER ST IN UCH C RPOR/�TIO
PARTNERSHIP OR TRUST: J / d / %
Issue to be lobbied(Describe in detail):
AGENCIES/:INIV UALA T 00-00190:
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
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 ,
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) ko 6 ff ae,,�6 L�e hj5d
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): ALO�(REQUIRED).
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":
_YesyNo: 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 Section 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 Section 2-482(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.
_Y*o: Are you reoresoffling a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UND OA H:
ON FEBRUARY'28 O EAC YEAR EACH LOBBYIST ILL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING E'PENDITURES AS WELLM COMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALMIENDA R YEAR. A STATEMENT§LHAILL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING TH REPORTING PERIOD.
Signat re of Lobbyist
do solemnly swear at all of tI a foregoing facts ar true an correct and a avp r or familiar with the provisions contained
in Section 2-482 of tt a Mia B If ach City Code and II rep i re it e
Signature of Lobbyis
Signature of Principa Client:
VI. LOBBYIST IDENTIFI TI P CIPAL IDENTIFICATION:
Produced ID Produced ID
/ Form i en ication - Form of Identification
Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida,County of Miami-Dade EEMh
tate of Florida,County of Miami-Dade
Sworn to nsubscribe before me EE LEONE worn a subscri before me
This day of JP� �20 ION#EE121164 his day of 0 ctober 16,2015 Discount Assoc.Co.
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Signature of Public otary—State of Florida Signat a of Public Notary—State of FI i rM E LEONE
Notarization of Lobbyist's signature Notarization of Principal's signature #EE121164 er 16,2015 TO BE COMPLET ED BY CITY CLERK'S STAFF ON Y i_ ount Assoc.Co.
AnrivaL Registrafion:fee: [ ]Yes[ _]No Amount,Paid.$ �' MCR# Date Paid
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-Lo.bbyi$t.Registration Form received,and,verified.by: ,1.Fc_\CLER $ALL\a FORMS\LOBBYIST FORMS\Lobbyist Annual'.Registration Forrn.doc ^ Revised,11/,18/1013
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MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granada,City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.741 1 ,Fax:305.673.7254
LOBBYIST MAINE:
1 understand that no later than February 23 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, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-435(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 2-435.1,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 30,shall be automatically
suspended from lobbying until all fines are paid, unless the fine has been appealed to
the Miami-Da un om 'fission n Ethics and Public Trust.
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Sign'AWre Date
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