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James P. Wurst - 3425 Collins, LLC. A;U MIAMI BEAC 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. WQM,7 \/A-0112 NAME OF LOBBYIST: (Last) (First) (M.I) AI Ml 3313Y_ BUSINESS NAME AND ADDRESS (Number and Street (Ciittyl-) r q�,(State) _ (Zip Code)) AWW-C&4� TELEPHONE NUMB FAX NUMBER: EMAIL: \� ,Please.notify this:office ff.your contact information:changes:address,phone, or e-ma�l,'address. . I. .LOBBYIST RETAINED BY: ?).%f 2::�S cd I I I W5, G r Mi NAME OF Tll VCC AL/CL N�T.�. ` �� BUSINESS AfAE AN AD RESS� umber and S reet) (City) (State (Zi Code) e0 7,3 TELEPHONE N MB R: 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: be- b- `e • IDENTIFY.ALL PERSONS HOLDING,DIRECTLY OR INDI CTLY,A 5%OR MORE OWNERSHIP NTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: W 1as...a K I_e•% Ze,Y% I; Eck) Issue to be to bled(Describe in detail): III. Will QS 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 tt V Atte 0 6 �J ex Pursuant to City Code Section 2.482(8)Every registrant shall be required to state the extent of any business,financial,familial or professionals 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 co r� F:ICLERI$ALLIaFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) A�UVJ% Z,� ` _1J� B) PRINCIPAL'S DISCLOSURE(OF LOBBY! COM ' NSATIO (REQUIRED). WIJWLA% 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": _Yeslvvo: Are you lobbvina 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 2490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _YesjNo: Are you lobbying on a pending application for a Development Aareement 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. _Yeshlo: 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 FILED EVEN IF T ERE WAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. n Signat bbyist I do solemnly swear that all of the foregoing facts are true land corgact and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami B ch City Code an all rting r uirements. Signature of Lobbyist: Signature of Principal/Client:_?C_ V tk� el�� VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID Produced ID Form of Identification Form of Identification /Personally known(Lobbyist) Personally known(Principal) , FRANCINEABRAMOFF VII. SIGNATURE AND STAMP OF NOTY , :�_ Commission#EE 112685 • ti. �o;= Expires November 15,2015 Oorded fire Troy Fein hwarm WO.365.70 State of Florida,County of Miami-Dade r. �d� to of Florida,County of Miami-Dade Sworn to and subscribed before rp a Sworn and subscribed bef re me This 1) day of 10 vemb 019 day ,201 q Signature of Public Notary—State f lorida re of Public Not=1' Wure Notarization of Lobbyist's signature N rization of Princi TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ Yes[ ]No Amount Paid.$ MCR# Date Paid Lobbylst Registration Form,received>and verified 1 by: F:�CLtRO�PALLFaFfD3 MSS LOB13V&ST,FORMS-�Lobbyist Annuall Registration Form.doc- Revised 01/22/2014 'ar°/• ANNET GONZALJ26,201 F:ICLERI$ALL1aFORMSILOBBYIST FORMS1Lobbyist Registration Form.doc °1. U#` Notary Public-State o My Comm.Expires Nov Commission#EE 8 d . i MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel:305.673.741 1 ,Fax:305.673.7254 LOBBYIST NAME: &4 A W wi 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 1 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,who fails to file the required Statement by April 301 of each year, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade Cou ty Commission on Ethics and Public Trust. Signature: Date: FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc CITY HALL CASHIER OFFI i/u0 CUN ENTION CNTR DR MIAMI BEACH FL 33139 08-.47'.10 11(14(2014 000000005148978 Merchant ID: 02013135 Terminal ID: 275202450886 CREDIT CARD VISA SALE VXXXY)(X)004120 CARD# 0001 INVOICE 001400 Batch#,. 013080 Approval Code: Swiped Entry Method: Online Mode: $0.00 Tax Amount: Cust Code' �B50'00 SALE AMOUNT CUSTOMER COPY t1q 014 Misceltaneous Cash Receipt Y a ,� � ,:'S50 wr ai c jY r, TY IF MIAMI BEACH 9' No. 361 Cash /Credit Card E Check# $ J _ OV 20 Received oft.-� 1/ d Address 6 1 A For 1 n 14, � ` ��v - s.-. -a - 4 '-; (THIS INFORMATION MUST BE COMPLETED) Offid of Finance Director By Account Number: Preparer: r. - .,. Dept: ,A�