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Adrian Dabkowski/Stiles Development - Mark Van Dyke~ MIAMIBEACH 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. Dabkowski Adrian K. NAME OF LOBBYIST: (Last) (First) (M.I) Kimley-Horn and Associates, Inc. 5200 NW 33rd Avenue, Suite 109 Fort Lauderdale Florida 33309 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (954) 535-5144 (954) 739-2247 Adrian.Dabkowski@Kimley-horn.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Stiles Development -Mark Van Dyke NAME OF PRINCIPAL/CLIENT: Stiles Development - 300 SE 2nd Street Fort Lauderdale FL 33301 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 954.627.9280 markvandyke@stiles.com 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: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Redevelopment of Southwest Corner of Collins Avenue & 69`h Street - Variance Approvals, and Conditional Use Permit Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship Planning Dept., HPB, BOA, Planning Board, City Commission * None :i `~) ~ i ~:~ ~ ~ to _ ~~ v '~ J V ~ ~ a ..~ ..a a i b -..J t.J' ,,,-1 1,~j * Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside of a public hearing setting. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHERf A) LOBBYIST DISCLOSURE: (Required) ~ 132 46 oer hour B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 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 X No• Are you lobbvina on a present or pendina bid for aoods eauipment or services or on a present or pendina award for aoods eauipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes X No• Are you lobbvina on a pendina 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 snot-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 X No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR MPEN N DURING THE REPORTING PERIOD. ~~i~~~ IL/ Signature of Lobbyist 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 Se ~on 2-482 the Miami Beach City Code and all reporting requirements. ~~~ C/' Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: Form Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: PRINCIPAL IDENTIFICATION: Produced ID Form of Identification Personally known (Principal) ~~"•°i;'•., 5FIIWDA UITONLAYNE State of Florid ~~ - ~-P1i;~AlUIi DD 49 1a State of Florida, County of Miami-Dade Sw rn`t, RBSAp I^ G,,, Sworn and subscribed before me Th~s, '' R; ' ~ o a pi Nose2 br writers ThIS day Of , 20_ Signature of Public Kotary -State of Florida Signature of Public Notary -State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature FOR CLERK'S USE ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid Lobbyist Registration Form received and verified by: Entered By: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM O5.doc Revised 12/08/04 rv. ~~: o~ zs n[~a~ao€tnns:~a~ ~oaa~s~ cor~sa~cir~ ~tris+c~. ~rri~z r~r~t r txn~~tr,~c3.~ orr: A7 lOSi3'7~i' 1?!~I-4S~ItE. (#€~q~ired) ~ 132 4fi yes htwr Bj I~RINGSt~AL'S`~~SGE:tJSi}RE' (AF fABB1FT5T Ct~MP'~15ATIt3N~. (f~eipfsirpidj. °$ Tf~e fol(byv~g :er~f>3tma~inn ~n~tsf ~ anss,srere~t L) ~ursisaii~to Miami Beath Ct'tjj ode ~Ctson 2-8 Ei-~fitl~f. "PrAkribfied ~inrpais~n Gomribui~Q>3s By Laibyists ~agr~atire t~' Ldbyisi; Signa~u~e o#.P~napalf~{tent¢ vi. PR~NG7AAi: SDEN7'Tf)tti I?r~ducer~ IL7 _ Fold ~# It3etrtfi"cafiori rYally krtgwti ~tc%~e~st~~ ~Pbi`sc~hally'kri©irin {RrniciAa~ wwa~ _ ~ vn.u„rt ~ .........................................~ R :L1F14 T4 ~Q Of ~br'1<1~, ~aut)ty pf N11dFTik E~3d£ CYNTHIA A. CLIFTON p„ StiVta ttd suhsc:~s'ib before me ,.~~'P~ cana,u eooaeza~s "°'~ T~ rla}r of ~€(~~~` exv~res vv2oo9 "~~ fl~~ ~~'~= arnwed mn, (eooWSZ-a2sa2 ~~1 '7q _ ~'!~~' FloridaNOlaryflssn. Inc wows w..wor...~....b....: - State of Fliitid~, S(gt~atut~ a Public otta~ry - ~ of Fkuda ~s s~nature: I+ftitarizatiori t~f Pi~'intipat's sigttatu ~ ~G1.Eii~'a' USE ONLY Annual Re~siraEl4n fie; E 1 [ l ~ Amount Paid ~ .~' Date Raid LDhbyisC tteglstraUort Frnrn rived and vcvified ~sy:._ - ~r~ecf t.u~aLU~uarn-JNSEObibpisc~C(~BYI3T'(Eittq o3,ioc ae~~ s2~oe City of Miami Beexh, 1700 Corrven6on Center D{rva, Miami Beath, Florida 33139, www,miomibeachH.gov CITY CLERK Office CilyCierk~miamibeachfl.gov Tel: 305.673.7A1 1 , Fax 305.673.7254 1.flBBY157 NAME: C~.V i Gt,Y~ ~~ Y, kw u ' `_. ~ c I understand that no later than Q~tober t s# of each year.. 1 must Eile 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. ~ ~' ~,/~~ Signature: Date: Revised 02J0~12048 l'':CT.i?R'.LC;1riIlYlST.rep_ „~iin.:< ,~: n;>~:~~,ti~ts:. Pont IU• d+x ~ ~ 0 c = 2 Z c 'n m ~ ~ n ~ ,~ z 3 ~ c ~ © ~ m ~t ; ~~ ~ .~c~ m v I~ m a .1 C7 ~ ~~ n 3~ ~~ C7 C7 ~ _ ~ t~D n -,._ i~; ~~ F :~; ~, r.. ~ :~i ii, °,=~ ;.. i ~: rr. ~'+ P.t z - '; O -- -_ ~;. r.~ _ _ 1~ _~ . \Q v - ~, ~`..n ~,