Allen M. Levine - G200 Exchange LLC A 1 I r °4
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City of Miami Beach Office of the Cily Clerk, .
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1700 Convention Center Drive, Miami Beach2FL033;139 u E "
LOBBYIST REGISTRATION FORM c ,' i f i l_•I:
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-mating 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.
Levrsly Ao N)
NAME OF LOBBYIST: •(Last) (FirsI) — - (M 1)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (Slate) (Zip Code)` 333a I
q514 7. 3' o. . Sy `'a sre..v$ hLedib.ge
TELEPHONE NUMBER FAX NUMBER: EMAIL:. 1
Please notify this office if your contact information changes:address,phone;or e-mail address.
I. LOBBYIST RETAINED BY:
6200 Ex
NAME OF PRINCIPAUCLIENT:
S��.1 ;.,� to 10x1. n '�•
, De jaw/( j q5(0/BUSINESS:NAME A ADDRESS '' (Number and Street) ' (City) (Stale). (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,PARTNER,OR BENEFICIARY: 4''o(d 5 LC A/71°r1
. IDENTIFY ALL PERSONS HOLDING.DIRECTLY OR INDIRECTLY.A 5%OR MORE OWNERSHIP INIEM ST IN SUCH CORPORATION,
I PARTNERSHIP OR TRUST:. L ■ it"• !/✓I _ 20 r
u.SPECIFIC LOBBY ISSUE:
Latina
Issue to tie.iobbied(Describe in detail):
III.CITY AGENCIES/INDIVIDUALS 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 cit•to the .resent dale,stain!'the.:eneral nature of the sub oct contractual rolationshi•
Sec 2-482(a)(4)Full Name'Of Individual and - Contractual Relationship(Explain) YES NO
title.ofjerson to be lobbied
171l -ro . pizE v, ,llc. ' ..► �C
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 bo lobbied as identified on the lobbyist registration form tiled.
Sec 2-482 • An Financial,-Familial or Professional Relationshi•
J :1 ► 1 q t
F:ICLERISALL1aFORMSILOBBYIST FORMSILobbyist Registration Form.doc r! A t
IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:.(Required) ]
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): l
(REQUIRED).. /j.0 f/,�
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: A : a.. _ n. •n . . e- .r .:n. n. . . f.r..... ..ul.m_ t.r I _ •r.,, : . n •r.• •In•
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 Agreemenj 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 lees.
—Yes No: 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 PRWEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR,
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
I du solemnly swear that all of tho foregoing facts are two 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; _v
Signature of PrincipaliClient;
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID —Produced ID
Form of identification Form of Identification
Personally known(Lobbyist) jPersonally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
�f w Yift/
State of Florida,County of Miami-Dade State of$evil ,County of Ntiemi'Bade-.et— y61-",
Sworn to and subscribed before me Sworn and subscribed before me
This day of ,201 This It day of_ 0. ....,.2015
sir* . State of New York of Public Notary-State of Florida Signature of Public otary-Stat of
Notarization of Lobbyist's signature Notarization of Principal's si, '': ki NeW 110111 1 OW
Dec.16,
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes( )No Amount Paid$ MCR# Date Paid
1 Lobbyist Registration Form received and verified by: _
i i•.V.LE%\:;ALL‘0F4itFta.L011t VIST FORMS Annual Registration Form. oc Revised 01/22/2014
F:ICLERISALL1aFORMSILOBBYIST FORMSILobbyist Registration Form.doc
s
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
"HOUR,14
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): .
(REQUIRED). Iott(�
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 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.
_YesXNo: 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 . SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED VEN IF THER . - E BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
"II%0P
Signature of 1,b•. t
I do solemnly swear that all of the foregoing facts are t ue an• • rect and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach City Co ,' i-•• _ equirements.
Signature of Lobbyist: /-400
Signature of Principal/Client:
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, r...--°. -..—
COLLEEN LAPLANT
State of Florida, County of Miami-Dade . (4)1:1 Commission#EE 880483 . State of Florida, County of Miami-Dade
Sworn to and subscribed before me .�' Expires June 16,2017 Sworn and subscribed before me
',,,�P�tt°0.- Bonded Thry Troy F ain Insurance 800.385.7019
This 5 day of j-r 6.1 , 201 - ..,,_,_,.>_..__...-:........_._. . This day of , 201
o Pi-AT-
Signature of Public Notary-State of Florida 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 ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by:
F:\CLFR,$ ,LL\aF RMS\LOS VtST FORMS Lobbyist Annual Registration Form.doc - Revised 01/22/2014
F:\CLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
i
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.mlomibeochfl,gov
CITY CLERK Office
Rafael E.Granada,City Clerk CityClerk @miamibeachfi.9ov
Tel:305.673.7411 ,Fax:305.673,7254
LOBBYIST NAME: ALLEN) LEV i l�
•
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$50,00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade •
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist,who fails to file the required Statement by April 30th of each year, shall be
automatically suspended from lobbying = :II fines are paid,unless the fine has been
appealed to the Miami-R ade County C sion on Ethics and Public Trust.
Aio615
Signature: Date:
F:ICLER1$ALL1aFORMSILOBBYIST FORMSILobbylst Registration Form.doc
Miscellaneous Cash Receipt " r�;.:L .YR�, � !S:/��.�_�2�.�I,t 0��i I�:�t •
'+ '+ a 550.00
CITY OF MIAMI BEACH
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For ( T)AAnwt rec.,m C') 14,,)(4e4,--- 0121#se_ an
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(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
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Account Number: Il"" ® "{369- I
Preparers Dept:
(?4-1-E47
L f irk EXT:- (7 i
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BECKER Colleen LaPlant
Phone: (954)987-7550 Fax: (954)985-6814
POLIAKOFF CLaplant @bplegal.com
1 East Broward Blvd.,Suite 1800
Ft.Lauderdale,Florida 33301
May 5, 2015
Via Federal Express
City Clerk Office
Attn: Patrick Camm, City Clerk
1700 Convention Center Drive
Miami Beach, FL 33139
Re: Lobbyist Registration
Dear Patrick:
Enclosed please find our Firm's in the amount of $2,550.00, along with the
Lobbyist Registration Forms representing lobbyist registration fees for Marcie Nolan,
Allen Levine and Kevin Markow on behalf of our client G200 Exchange LLC.
Thank you for all your help and assistance. If you need additional
information, please feel free to contact me.
Sincerely,
eja,e-e )
Colleen LaPlant
Executive Assistant
CpZr�
Enclosures
ACTIVE:5753230_1
www.bplegal.com care @bplegal.com
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