Mark Van Dyke/Publix Super Markets4
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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.
Van Dyke Mark
NAME OF LOBBYIST: (Last) (First) (M.I)
Stiles Gorp. 300 SF. 2..nd Street, Ft. Lauderdale, F"L 33301
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
954-627-9195 954-627-9288 markvan(~stiles.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
Publix Super P~`arkets
NAME OF PRINCIPAUCLIENT:
3300 Publix Corporate Parkway Lakeland, FL, 33815
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
863-688-7407
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
is section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
Publix Super Market, 6876 Collins Ave., redevelopment. Application
Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to Ciry code section 2-482(g-
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Mayor Matti Herrera Bower N/A
Coalrtissioner Saul Gross N/A
Con~nissioner Jerry Libbin ]~?/A
Cot7I; issioner Richard Steinberg 1~?/A
Co>~Inissioner Edward L. Tobin N/A
Corclrtissioner Deede Weithorn I~?/A
Cortanissioner Jonah Wolfson I~?/A
Planning Board r?/A
Design Review Board r?/A
Board of Adjustments 1~?/A
review by
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): $lOO per hour. TI11S fee is inclusive in the client/principle
A) LOBBYIST DISCLOSURE: (Required) service agreement for the z~edevelopment of the property,
same as above
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). ~c,~- ? M ~ Sc~ ~_
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 `LJ'NO: Are you lobbvinq 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 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~NO: Are you lobbvinq 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 2-484 (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 anot-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.
^ Yes ~O: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
see a
VI. LOBBYIST IDENTIFICATION:
y~..o.
°.pxY ooh Notary Publlc $f~ta of Florida
+ Eileen S Hous Produced D
'~ My CommissionDD600460 Form of Identification
~O-~°~ E fires 11/ 201
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Mi ade
Sworn to subscri e.~ore,m
This ~ da I~A~X( .2008
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signa el-6~ lic Notary =State of Florida Signature of Public Notary -State of Florida
Not zatio 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:
~:~,C~~€e~rL~~~s~x~~r,~.~b~yist Regi~tr~?ovra ro~~m 3~?a~3k3.~lrsc Revised 03/27/2008
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 efthe Miami Beach City Code and all reporting requirements.
a. cQ~snTEO t_ossnsT:
The City of Miami Beach Code sub-section 118.31 rewires the disclosur>r of any individual or group which has
been, or will be, compensated to either speak in favor of or against a project being presented before any of
the City's Devekspment Review Boards, or not to speak at ail, Please Ilst below ail persons or enl3ties
encAmpassed by this section.
NAME ADDRESS Ft10NE # TO SPEAK NOT TO
a Nelsen O. Kasdin 1 SE 3rd Ave, 33131 (306} 9&2 5629 X PRa CON SPEAK
b Andrew Frey 1 SE 3rd Ave, 33131 {305} 982.5510 X
G Mark Van Dyke 3013 SE 2 St, 3330~~1~~~~ X
Additional names can be placed an a ~~parda~e page attached to this form-
* t)isdosure shall no# be required of any entity, the equity interest in which are regularly traded
on an established securities nsarkefi in fibs Onited States or other opuntry, or of any entity, the
ownership interests of which are held in a limited partnership consisting of more than 5,000
separate interests and where no pne person or entity holds more than a totaE of 5°l0 of the
The applicant, hereby tYiat the dtsr~sure information meted ~ this appication is a fuU d~xlasure of aN parties of interest h this
application to the best of my knowledge :mod belief.
dfe suds q~f a C~ of Miami end al! o+tlrer pe ~t Inancx~s.,
PERSgq SUSMI7TINCi APPISGITIOH:
nature
rd7.1
Print Name
STATE AFFILIATION WITH APPLICANT (i.e. Agent, Architect, Attrmey, Contractor, a4c.)
sus-11 sa
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bX~]~L~~~~ has ixodu+ced
didJd~d not take an oath.
STATE OF FLORIDA
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MY COMMISSION EXPIRES:
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City of Miami Beach, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: i, ~~~c~.r!~-- _ 1..- -1k~u >)U I~
I understand that no later than October 1st of each year, I must file the following
forms, 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 Form
2) Disclosure 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, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: ~'- ~, ;' Date:
i~:~viseci 02.,o~ir~oos
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