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Alfredo J. Gonzalez - Jefferson Avenue Hholdings, LLC 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. _ Gonzalez Alfredo J NAME OF LOBBYIST: (Last) (First) (M.1) Greenberg Traurig, P.A. 333 NE 2nd Aven Miami FL 33133 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-579-0588 305-961-5588 gonzalezaj@gtiaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. 1. LOBBYIST RETAINED BY: Jefferson Avenue Holdings, LLC - NAME OF PRINCIPAUCLIENT: 300 NE 71 Street Miami Florida 33138 BUSINESS NAME AND ADDRESS. (Number.and Street) (City) (State) (Zip Code) 305-785-3440 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: Donita Leavitt • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: n.SPEGIFI LOBBY 1SWIt BOA& HPB 635-643 Jefferson Avenue Issue to be lobbied(Describe In detail): III.CITY..AGE NCIESANDIVIDUALS: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 eneral 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 Board of Adjustment,Dept of Public Works,Historic Preservation Board N/A City of Miami Beach Commissioners,City Manager,City Attorney,Fire Dept. N/A Planning Board,Design Review Board,Building Dept.,Planning Dept. Floodplain Management Board N/A 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 Any Financial Familial or Professional Relationship None C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outiook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc ............. - - ...._-.._... _.. . _......_...__..._.... ......... __ .. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) Hourly 500.00 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). Hourly 500.00 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 XNo: Are you lobbying on a present or vending bid for goods,eguipment 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 jXNo: Are you lobbying on a pending application for a Develooment Agreement with the City or application for change of zoning map designation or change to the Cites 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. —Yes XNo: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 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 FJLED.EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Sign e o yist I do solemnly swear that all of foregoing facts are tr r!-eorrect and that I have read.or am familiar with the provisions contained in Section 2-482 of the Miami a e and all reporting requirements. Signature of Lobbyi Signature of Principal/Clie VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: �• `aa _Produced ID 1'"L �%J��S C- • v �.� do a ye. _Produced ID Form of Identification Z1 oo Q Form of Identification oQ o`er a o Personally known(Lobbyist) ��'\ Q °cam Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: �� F .y �� • �� /� Co Ci State of Florida,County of Miami-Dade �� a�a State of Florida,Ca?w.oi'iiget�a�d Sworn to and subscribed before me 3oc o° Sworn nd subscr' Before me �m• This day of 201 '*a This day of :b �'i'8t2"'iQ O9 y ure of Public Notgry–St1 e o f Florida "" Sig ature of PulAc Notary– •��p��o°� Notar ation of Lobbyist's signature Notarization of Principal's sig TE �IIIIIIIIN�� TO BE COMPLETED BY CITY CLERK'S STAFF ONLY e7/*7/ Z_/ Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: C:\Users\clerhatlW ppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc 3 .r ti P n $ ' ..w;,a' 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 NAME: �• ��- �-- I understand that no later than February 28 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 2-485 (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, ho fails to file the required Statement by April 30, shall be automatically suspended fr m lobbying until all fines are paid, unless the fine has been appealed to the Miami- de County,Commission on Ethics and Public Trust. Si at r — Date FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc • ,, a 0 a::: _ 0 � C W cA Jm . ,F -� CD v Zri - a ' o �.... m -N9 _ " . - 1 v:_. o