Mathew Pargament/AB Green Raleigh, LLCL U .- 12 t~-l, C 1 f~ k', ~"~-oiler
m MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL
LOBBYIST REGISTRATION FORM
33~39..1i~~' 22 P~ I2= 33 _
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 bond 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.
NAME OF LOBBYIST: (Last) (First) (M.I.)
Par ament Mathew
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
AB Green Ralei h, LLC. 1775 Collins Avenue Miami Beach FL 33139
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
305.534.6300 305.673.8181 Mathew.Pargament@hotelsab.com
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
AB Green Ralei h, LLC.
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
The Ralei h Hotel 1775 Collins Avenue Miami Beach FL 33139
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
305.534.6300
Fill out this section if principal is a Corporation, Partnership or Trust (Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Andre Balazs, Chief Officer
• IDEI~.,IFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE
OWN~RSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
Please see attached
II. SPECIFIC LOBBY ISSUE:
Conditional Use Permit for Raleigh Hotel
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESlINDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2-482(g} include a
statement of the extent of any business, financial, familial, professional or other relationship, giving rise 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 An Financial, Familial or Professional Relationshi
Mayor None
Commissioners
City Administration; City Attorney's Office; None
Cit Committees; Cit Boards
~~
y
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
No special compensation (lobbyist is an employee of the hotelL
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). No special compensation (lobbyist is an employee of the hotel)
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":
f-lYes ~ No• 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 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^Yes ~ No• Are you lobbying on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or chance 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 ®No• Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
Ily own (Lobbyist) ^ Personally known (Principal)
I~ATUR ND STAMP OF NOTARY:
la, Cou of M' i-Dade _ ,~,,~r at of Florida, County of Miami-Dade
sub i d b o m ~J"r'"' ! of F~o~~Swo ands r bed before me
of P~p~'~ o0 5~~This day of`, 200
No~aH A
. Dndsrt~~m1ssr a~z
bli ry ~ M~tree oyo~ Signature of Public Notary -State of Florida
mf bbvist's Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S USE ONLY
Annual Registration fee: ( Yes [ ] No Amount Pald S MCR # S Date Paid
Lobbyist Registration Form received and verified by: Revised 03!2712008
F•\nl FRU nRRYISTLohbvist Registration Form 32708.doC 17~f
I do solemnly swear that all of th oregoing facts are trund correct and that I have read or am familiar with the
provisions contained in Section 2-~2~of the ~i Beach Code and all reporting requirements.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
No special compensation (lobbyist is an employee of the hotel)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). No special compensation (lobbyist is an employee of the.hotel)
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 ®No• Are you lobbying on a present or pending bid for goods equipment or servicess_ 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 lobbvina on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or chance to the City's Future Land Use Map?
3) Pursuant to Miami Beach Ciiy 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 ®No• Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
PERIOD.
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 Section 2-482 of the Miami Beach City Code and alf reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: ~
VI. LOBBYIST IDENTIFICA'
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This _ day of , 2008
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
^ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, County of Miemr~-dde
Sworn to and sub cribed before me
This 1~ day ofd, 200
Signature of Public Nota -State of Florida- !'-~y
Notarization of Principal's signature
~ z
n~ o
~~~~
~3°~~
~~o~
~~~,~ ~yy
''__7t'N~ 50
Tbna~ A
J o
R
TO BE COMPLETED BY CITY CLERK'S USE ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Pald $ MCR # $ Date Pald
Lobbyist Registration Form received and verlfled by:
F'\CLER\LOBBYIS11Lobbyist Registration Form 32708.doc Revised 03!27!2008
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK office CityClerk(c~miamibeachfl.gov
Tel: 305.673.7411, Fax: 305.673.7254
LOBBYIST NAME: Mathew Pargament
I understand that no later than October 1g~ of each vear, 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 for lobbyist withdrawal in writing.
X 6~s~
Signature: Date:
MIADOCS 3498108 1
0
c~
D
NZ_
D
O
Z
D
r
C7
D
-~
m
r
_m