Rafael Andrade - Surterra Florida, LLC /-1691 CA. /14A-0 4 Jt..-/+-,r-)9-
PEACHFQ
Office of the City Clerk RECEIVED
1700 Convention Center Drive
Miami Beach, FL 33139
305.673.7411 2011 JUL 25 Ph 1: 10
LOBBYIST REGISTRATION FORM t CI.TT�Y CF MIAMI TBEACH
Lobbyist means of persons employed or retained, whether paid or not, by a principal who stlaket� Ac__t tFYeVa e, 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:
Andrade, Rafael
NAME OF LOBBYIST (Last) (First) (Middle Name)
Law Offices of Rafael E. Andrade, P.A. 1224 Washington Avenue Miami Beach FL 33139
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 531-9511 (305) 216-2028 ralph@arandradelaw.com
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
Surterra Florida, LLC
NAME OF PRINCIPAL (Last) (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 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 2482(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: Surterra Holdings,Inc. (100%)
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
proposal,invitation to bid,or public hearing number. fit '.
Any and all regulations related to medical mari'uana and • • .' pursuant
to the Florida Constitution and Florida Statutes
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
Mayor and City Commission,all City Boards and X
Committees, City Attorney and staff, and City Manager X
and staff. X
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:
N/A
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":
_Yes XNo: 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
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 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 city clerk as required by this section,but shall not be required to pay any registration fees.
_Yes XNo: 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,
_-Yes xNo: 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
form And shall orally disclose such particular service before lobbying the City Commission at a public meeting.
_Yes xNo: 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 members)of the City Conimission;
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 LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD'
Signature of Lobbyist: Date 7/2.5//7.,
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 am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code and all reporting requirements.
IP - /2- r/( ---? '
Signature of Lobbyist: AdilL .. Date
Signature of Principal: / I Date 14
VII. NOTARY SIG ATURE AND SEAL:
LOBBYIST: PRINCIPALrr
•
State of FROM D/L State of l7 e o n,/ Q-
County of: CA.(Pim I-9A-DC- County of: Fi��c,./ 1t n
Sworn to(or affirmed)Rnd subscribed before me Sworn to(or affirmed)and subscribed before me
this n$ day of J Lot , 20117 by this Z day of J a Iy , 2016,by
2,3cla o,g_ftr,
Rcber1mJeo1, gcr tea.h h
NAME OF LOBBYIST NAME OF PRINCIPAL yg
_Produced ID XProduced ID PAsSf 0 rt
FORM OF IDENTIFICATION FORM OF I ENTIFICATION
1/ Personally Known _Personally Known
fit1.41Li<a. g` `/_ — l
Sign ppee�of Notary Public Signature . Notary Public
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J .SAL1 bl(, - Uf 11 a - R '
Name of No - --- JASON.-.-�-.-0-- Name of otary,Typed, Pri1 T•r+ y �.t - � '
'-•'..A ' MY COMMISSION p GG 030527 1 `^ C
(NOTARY S i. ' EXPIRES:September 14.2020 (NOTARY SEAL) " tateFulton Georgi
'a- State of Georgia
�•'%EOF S Bonded Thru Notary Public Underwriters
•• , •• - My Comm. Expires January 3,2021
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: I I Yes I No Amount Paid$ _ ' o a _ MCR# f/(�j4;'. , Date Paid • ._M
Lobbyist Registration Form received and verified by: 7 • .,
Ft\CUR\$M.1.\afORM 9 LOBBYIST FOl MSi;.obbyi t R it/Paz/deo Form 08._18-16 REG.tioc Revised 08/1.8/2016
'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.
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 LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD.'
Signature of Lobbyist: Date
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 am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: Date
Signature of Principal: � i Date fftl-//14
VII. NOTARY SIG ATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of State of 6€ 0 r9 / 4.
County of: County of: Fa./ /111
Sworn to(or affirmed)and subscribed before me Sworn Jo(or affirmed) apd subscribed before me
this day of , 2016, by this Z`) day of J u, ley , 2016, by
Robert Jacob �r,,• tti►ahh
NAME OF LOBBYIST NAME OF PRINCIPAL 9
_Produced ID Produced ID PASSE o rt
FORM OF IDENTIFICATION FORM OF IddENTIFICATION
_Personally Known _Personally Known
110.
Signature of Notary Public Sig..nnc'ature . Notary Public
Up
Name of Notary, Typed, Printed or Stamped Name of Notary, Typed, PrAilvf.'�W IC
(NOTARY SEAL) (NOTARY SEAL) Fulton County
State of Georgia
My Comm. Expires January 3, 2021
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:\CLER\$ALL\aFORMS\LOBBYIST FORMS Lobbyist Registration Form Revised 08-18-16 REG.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.
4
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www,miamibeochfl.gov
Office of the City Clerk
Rafael E, Granada, City Clerk CityClerkmiomibeachfLgov
Tel: 305,673.7411, Fox: 305..673.7254
NAME OF LOBBYIST: Rafael E.Andrade
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
commencing October 1 of each year, and the fee for such annual registration shall be
$500.00 pursuant to Section 2-482 of the Miami Beach City Code..
Signature of Lobbyist Date
F3ICLERASALL1aFORtu1S11.088YIST FORMS1Loebyist Registration Form Revoked 08-18-16 REG.eoc
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