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James P. Wurst - Washington Squared Owner LLC . e Gm-60/ y� /��a5�}. V r' a MIAMI BEA H City of Miami Beach Office of the City Clerk 6 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 10 jfc7r NAME OF LOIST� (Last) (First) (M.I) W e i�( ic 4uA- M/6 &* ,�� el "$48 USINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 443®�?o� 1416- ��3®�/ m w 4, A b wu.s cow. TELEP NE NUMBER: FAX NUMBER: EMA1 Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: ladOsiAitt r S V A 040 0 U OIL' II4rero NAME OF PRINCIPAL/CL E Tit MI • It' BUSINESS NAME AND A E�S��t ,.r;member. 1-�=et Cit • :®�_ ( '�:�`r•--)� • CIL' 63 IM ( y) (State, C Co. _ 1 .r_,`_ ,,. . , NA TELEPHONE NUMBER: FAX N BER:(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: L)1O1.4 • IDENTIFY ALL PERSONS HOLDING DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: NA' ILSPECIFIC LOBBY ISSUE: . ; ,�..::,. Autb , �. ,r, • __ ail. ►.: 0 Issue to be lobbied(Describe in •etail): tt r' -41.44c4.l 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 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 13e7/4° K I a.e *bad. it. Sil t)etek.t. % it lotresetiValvii pti K CAI GNAP-th•-:%lb,t6N". -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 be lobbied as identified on the lobbyist registration form filed. Sec 2-482(g)Any Financial,Familial or Professional Relationship 04j6 1 F:\CLER\$ALL\aFORMS\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 tjgc boo I Few ikow B) PRINCIPAL'S DISCLOSURE(OF LO:;YIST C MPENWLION): (REQUIRED). �, 10 O The following information must be answere : 1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _YesNo: 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 XNo: 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. _YeAlNo: 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 RECEIV D, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN H E HAVE EEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and _orrect ,nd that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Be- -"=-i y- ode and all r-,�,�z"j.�nq --- Signature of Lobbyist: I, ailitt Signature of Principal/Client: - 1.4_m VI. LOBBYIST IDENTIFICA ION-- PRINCIPAL IDENTIFICATION: Produced ID F DL, u3(02.Z ,5-Z. -- /Produced ID Fb l.43( f �� .f, O O-- Form of Identification °`' Form of Id ific:,' c.7) . ;.-:......:,....,f p..I Personally known (Lobbyist) CO*�� :t Personally known (Principal) '44,,,o;..�... VII. SIGNATURE AND STAMP OF NOTARY: -1 o C ... l State of Florida,County of Miami-Dade ° r State of Florida,County of Miami-Dade :p. . Sworn to and subscrib-. before me Sworn nd subscri•ed before me �. .(1) Ai 74,This day of '4(,1�,�_ ,201 >y`g. • �' This` . day of `l_.!_ ,201-5 • y / AV' ! ; ai / t. /�i Er AO did 4. i;nature of Public Notary–State of Florida "•∎i:'at e of Public N•'ary–State of Florid.' 4 it Notarization of Lobbyist's signature S'^,I.Not:rization of Principal's signature o �d . TO BE COMPLETED .Y ERK'S STAFF ONLY Annual Registration fee: [ ]Yes ]No Amount Paid$ 3 6,, 6 MCR# 9 OL4 l P 1 Date Paid l2,//— Lobbyist Registration Form receiv4dand verified by: 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 a* M1AM BEACH 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: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: c,)ELM c P \AV 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 until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. 6 24 ioLf Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc fi Miscellaneous Cash Receipt ' ; ' �" ; xr ':t ;��,= r , gg q r� CITY OF MIAMI BEACH F No. p 4 1)5 0 ❑ Cash Credit Card ❑.Check# $ -T5 1ii ' 20 J c v Recei ed of 7a Address 16( A 1#,. , v E For 601' ()OS ti Sit; c)im A Lc (1 55e. (THIS INFORMATION MUST BE COMPLETED) Office of Finance Direct -. ' By Account Number 011 r-- ?Do( °' b -11` tr C (/ < xPreparer. . ei .. Dept: t CITY HALL CASHIER OFFI 1700 CONVENTION CNTR DR MIAMI BEACH, FL 33139 06/23/2015 14:58:45 Merchant ID: 000000005148978 Terminal ID: 02013135 275202450886 CREDIT CARD VISA SALE CARD# XXXXXXX " 5011 INVOICE 0011 City of Miami Beach-Florida Batch #: 001567 Finance Department Approval Code: 05376G Entry Method: Swiped 1 City Hall Mode: Online 1517413-1 06/23/2015 BR1 T137 Tax Amount: 50.00 Tue Jun23,2015 02:59PM Trans#33-33 33 $350.00 MCRCLERK - MCR-City Clerk SALE AMOUNT $350,00 * MCR#: 404819 1 ITEM(S): TOTAL: $350.00 Credit Car PAID $350.00 CUSTOMER COPY Have a nice day!