David Custin - Surterra Florida, LLC Me9tCAA—Mt tJ A,/c.,44v.N:413.0
Office of the City Clerk RECE�.
1700 Convention Center Drive
Miami Beach, FL 33139 20/74x
24
305.673.7411 Clry op PM 4:S9
LOBBYIST REGISTRATION FORM Orr'CE OF 4!hI BEACH
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage�tne ge, 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 City Code Chapter 2, Article VII, Division 3, entitled "Lobbyists,"
for additional information.
Instructions: Please complete all sections of this form and submit the completed form, with the applicable fee,to the Office of the City
Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular
section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City
Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form.
The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs.
Separate registration forms shall be required for each principal represented on each specific issue.
I. LOBBYIST INFORMATION:
Custin David R.
NAME OF LOBBYIST (Last) (First) (Middle Name)
David R. Custin & Associates, Inc. 5001 SW 74th Court, Suite 209, Miami, Florida 33155
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-607-8576 305-607-8576 CustinDR@DavidRCustin.com
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
Surterra Florida, LLC
NAME OF PRINCIPALLast
( ) (First) (Middle Name)
-Surterra Florida, LLC 1639 Village Square Blvd. Tallahassee FL 32309
PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
404.920.4890 Ext. 5050 N/A tdriscoll@surterraholdings.com
PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code
Section 2-482(c):
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Jake Bergmann, CEO
• NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:1 00% Surterra Holdings, Inc.
III. ISSUE TO BE LOBBIED:
Describe with as much detail as is practical, including but not limited to a specific description where applicable of a pending request for
p osal, invitation to bid or public hearingnu ber.
All regulations relatedrto e 'medical marijuana + -. : . Treatment Center d „.
410
pursuant to Florida statues and the Florida Constitution.
IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City personnel sought to be lobbied,and whether the
lobbyist has entered into any contractual relationship(paid or unpaid)with said City Commissioner or City personnel from 12
months preceding such commencement of service with the City to the present date, stating the general nature of the subject
contractual relationship.
Full Name of Individual and Contractual Relationship(If yes,explain) YES NO
Title of Person to be Lobbied _
City Manager, administration staff, & City Attorney's office None
Commissioners Grieco and Malakoff Consulting&/or communications services ✓
All other members of the Commission & Mayor 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.
List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance of
impropriety:
None.
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a
contingency fee is prohibited pursuant to City Code Sec. 2-485.3):
$5,000 per month
The following five(5)questions MUST be answered:
1) Pursuant to City Code Section 2-488, entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues":
Ye)✓14o: 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 City Code Section 2-490, entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development
FIsIsuel •
Yel♦ IO: 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 City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in
Section 2-481) 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 cit clerk as required by this section, but shall not be required to pay any registration fees.
Ye o: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement?
4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who
provide only scientific,technical or other specialized information or testimony in public meetings; any person who only appears
as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct,
indirect or contingent,to express support of or opposition to any item;and any person who only appears as a representative of
not-for-profit community based organization for the purpose of requesting a grant without special compensation or
reimbursement for the appearance.
Yeo: Are you providing only scientific, technical or other specialized information; appearing as a
representative of a neighborhood association without special compensation or reimbursement or
representing a not-for-profit based organization for the purpose of requesting a grant without
special compensation or reimbursement?
5) Pursuant to City Code Section 2-482(a)(4), a lobbyist who has within the past election cycle provided campaign consulting
services to an incumbent member of the City Commission shall disclose such particular service on his/her lobbyist registration
m and shall orally disclose such particular service before lobbying the City Commission at a public meeting.
YenVo: Have you provided campaign consulting services to an incumbent member of the City Commission
within the past election cycle?If yes,please list the incumbent member(s)of the City Commission:
Commissioners Aleman and Arriola and Mayor Levine (2015); Commissioners Malakoff and Grieco (2017).
If yes, you must also orally disclose such particular service before lobbying the City Commission at a public meeting.
VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGED TO LO BY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR CO ON RIN HE - = •RT 1 i •ERIOD.1
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Signature of ' r // /
g e Lobbyist: \ 4 Date Q / z e ( 2 J /
C
I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct,
and that I have read or a'- am with -- pro 'sions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City C..e and all -p'. ing re.• r-ments. A
Signature of Lobbyist: — f Date / 2 41 /2 0
Signature of Principal: j� D
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VII. NOTARY SIG 140<URE AND SEAL:
LOBBYIST: PRINCIPAL
State of Ylo12.‘a0, State of GeocEGth
County of: M'-M 1 -.)ie County of: �r-6,)
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Sworn to (or affirmed)and�ubscribed before me Sworn to (or affir ed)and subscribed before me
this o� 4 day of c�U , 201$-by this [ day of '•.L y , 2013,by
�rN,d �erJe uS+►� koPEa.1 J'a6 6E26mA-J/J
NAME OF LOBBYIST NAME OF PRINCIPAL
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FORM OF IDENTIFICATION FORM OF IDENTIFICATION
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Signatu e of Nortary ublic Si_�tu= of otary public / `,N*OSiPr i'�
Name of Notary, rpq inteci or w@hi HELL Narn of Notary, Typed, Printed e Cp. Prf--Sc , sA,'t amp
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(NOTARY SEAL) _ MY COMMISSION#GG 054808 - _III-411, .e.
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=°41 ^&' ;*a EXPIRES:April13,2021 (NOTARY SEAL)
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"4°'-;off:` Bonded Thru Notary Public Underwriters • Jun fS,2021 •
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ,f~',NT 4;.04e=0°0,'Annual Registration fee: [1i]/es[ ]No Amount Paid$ 'L CR# A' ' Q
Date Paid �V► �`�
Lobbyist Registration Form received and verified by: '�.� , L _ON% N,f /�V//?
i=:,CLER\$ALL\aFORMS\LOBBYIST FORMS\Lubbyist Registretior Form Rev sed 08-18-46 RES.doc Revised 08/18/2016
1 The term"lobbyist"specifically excludes the following persons:
Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who
only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether
direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of
not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for
the appearance.
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
Office of the City Clerk
Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov
Tel: 305.673.741 1, Fax: 305.673.7254
NAME OF LOBBYIST: David R. Custin
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT
Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or
principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement
(Statement). In addition to any other penalties that may be imposed as provided in
Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyist expenditures, as well as compensation
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I understand annual registration of all lobbyists shall be required for each 12-month period
commencin• October 1 of each year, and the fee for such annual registration shall be
$500.00i.nt to Sect•• 2-4;2 of the Miami Beach City Code.
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Signature of Lobbyist Date
F\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc
Salvatore, Jason
From: Terese Cerna Driscoll <tcernadriscoll@surterraholdings.com>
Sent: Monday, July 24, 2017 5:31 PM
To: Salvatore, Jason
Cc: Nicholas Monette
Subject: Re: Missing Principal Information For Miami Beach Registration
State: Georgia
County: Fulton
Principal: Robert Jacob Bergmann
Date:July 21, 2017
Thank you Jason. We hope this info is helpful in processing our application. Please call me if there is an issue..
Terese Cerna Driscoll
Chief of Staff
Surterra Holdings Inc.
(404)420-4890 x 5050
On Jul 24, 2017, at 5:26 PM, Salvatore,Jason <JasonSalvatore@miamibeachfl.gov>wrote:
Good afternoon,
Please provide the State and County which notarization of the Principal took place. We also need the
date that this signature was sworn to or affirmed, as well as the name of the individual who signed as
Principal representing Surterra Florida, LLC.
Thank you,
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Jason Salvatore - Office Associate Ill
Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
Tel: 305-673-7411 www.miamibeachfl.gov
We are committed to providing excellent public service and safety to all who live, work and play in our
vibrant, tropical, historic community.
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