David R. Custin - Ocean Drive Restaurant LB, LLC I
1 OS ZD ceCiAd rivt
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.
Custin David R.
NAME OF LOBBYIST: (Last) (First) (M.I)
David R. Custin & Associates, Inc. 6401 SW 113 PL, Miami, FL 33173-1083
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-607-8576 N/A CustinDR @DavidRCustin.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Ocean Drive Restaurant LB, LLC
NAME OF Drivel Restaurant LB, LLC 1331 Brickell Bay Dr. Ste 2705, Miami FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(3'OS) 790 -7 9 Z N/A
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:
iNJ s`L- v. iat-YUNIA 51__
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: &N kAO-AjlJ MilY)4 L 1 t t ( C1LrL 4f\1&cf N I cso n1
II.SPECIFIC LOBBY ISSUE: 14L-13f1-70 C-C% k 'O oe 4 -`R um rtiJ 3 4 O4Jv
Planning Board matter and City regulatory actions. / .� 5.z oc� Ap_,)',,`� 6 ,,• � ��
Issue to be lobbied(Describe in detail): •
. Ill 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 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
City Manager, administration staff, & City Attorney's office None I
•
Mayor& Commissioner Grieco Consulting &communications services 17
All other members of the Commission None
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
Not applicable.
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
i
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $1,000 monthly fee
B) DAL' DJS U1RmoOntQIiy reeCOMPENSATION):
(REQUIRED). 1 U j'lyI
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues":
_Ye$.✓ o: 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":
nYeWo: 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.
[1Ye1o: 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 , -EN ON RECEIV !, ,THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT HALL BE ED E A F T RE H•;, BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. _ 4
Signature of Lobbyist
I do solemnly swear t ,.:t all of the e -_sing f.A are e an cor ect and that I have read or am familiar with the provisions contained
in Section 2-482 of the k iami Beac/ ity Co- • ° Ire n s.
Signature of Lobbyist: :'
Signature of Principal/Client:
co •n
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: o N
Produced ID CO Produced ID z o
Form of Identification N Form of Identification y c
/ W - i3 w
/Personally known(Lobbyist) °° . ✓ Personally known(Principal) ° cc
Y ( Y )
O
VII. SIGNATURE AND STAMP OF NOTARY: °°
State of Florida, County of Miami-Dade x State of Florida, County of Miami-Dade • '! r
Sworn t• . d subscribe• before me * Sworn acid subscribe efore me roti �v::.•�t'N'
T•' ' day of 0 ,2011 ,�, ��,;-"o.�o This I'1 day of ,2016_ * g■I_E-.-.ti; idlipLaZ .041
X11 •
Sign. ure of Publ/Notary—St. of Florida r°4'/*. -_,L, Signature of Publi�j otary—Sta of Florida
Notarization of , •bbvist's s'S . •ture Notarization of •r1' ci•al's si• ••ture
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ n No Amount Paid$ 3S0.°° MCR# 9O`11"0 Date Paid _
Lobbyist Registration Form received and verified by: C/ate /st, itaSev
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
i s
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeochfl.gov
CITY CLERK Office
Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME: David R. Custin
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, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
ppea o t e Miam ad = mission on Ethics and Public Trust.
c772
tii� 6.
Signature: Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
CITY HALL CASHIER OFFI
1700 CONVENTION CNTR DR
MIAMI BEACH, FL 33139
14:32:31
05J19J2015 000000005148978
Merchant ID: 02013135
Terminal ID:
275202450886
CREDIT CARD
VISA SALE
CARD# )00000O000000331
0009
INVOICE 001537 City of Miami Beach-Florida
Batch #: 06917G Finance Department
Approval Code: Swiped
Entry Method: Online 1 City Hall
Mode: $0.00 1513913-1 05/19/2015 BR1 T121
Tax Amount: Tue May 19,2015 02:33PM Trans#13-13
$350.00 13 $350.00 MCRMISC - MCR -
SALE AMOUNT Miscellaneous
* MCR#: 404141
1 ITEM(S): TOTAL: $350.00
CUSTOMER COPY Credit Car PAID $350.00
Have a nice day!
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CITY OF MIAMI BEACH �:�
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Preprer.
City Of Miami Beach
Lobbyist Fee Expenditure and Compensation Form
City Code Section 2-485
Due:February 28,2016
r
Expenditure for period of:1/1/2015 through 12/31/2015
A statement shall be filed even if there have been no expenditures or compensation during the
reporting period. In order to withdraw as a lobbyist on an item which is no longer being lobbied,
initial in the box labeled "Withdraw".Any item requested to be withdrawn will be removed
for the reporting period of: 1/1/2015 through 12/31/2015
"1.i,,"li-,I:4=M David Custin
I
Attire 41 y Ocean Drive Restaurant LB, LLC.
1052 Ocean Drive, Miami Beach, FL 'Withdra
t4,44. ....,IiiYES1 NO_
_= .1s - DATE / / 1g
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Detail Compensation Received: 0 .-
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CATEGORIES OF EXPENDITURES I
Food Beverage:
Entertainment:
Research:
Communications:
ki (s.c.
1
Media Advertising:
Publications:
Travel: f ,•
Lodging: if ,
Special Events: .
Oath
State of Florida
County of Miami-Dade
I,the undersigned lobbyist,do hereby depose under oath and affirm that : nforma • • • here
attachment hereto are true and correct. 1
O N Cp• vc I0
.�/t Signature i- ° Q z
Sworn to and su•- : • •e••r m:4)1 - . 02 day of ,20
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Notary Public 4 W °• c:
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My Commission expires: 7 17-/70/� 1 o 4
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This form is to Drive,Miami Be ch,FL 33139 b notarized ebrua returned 8th.k ne of$50.00 p r day Beach,shall be assessed for reports 0 fl filed after the due ,.�?" ,�,, k/
Y February per Y
date. If you require any assistance please contact this office at 305.673.7411 or at Cityclerk c@miamibeachfl.gov. 4�`�� b° �p
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