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David R. Custin - Globetec Construction, LLC.. ~ T6 ~~, o~/~o 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 aty board or corrtndttee; or any action, tleasion or recommendation of any city personnel during the time period of the entire deasion-making process on such action, derision or recommendation that foreseeabty will be heard or renewed by the city commission, or a city board or committee. The term sperifieelty inGudes the prinripal es well as any employee engaged in lobbying activities. The term "lobbyists" has specific exclusions. Please refer to Ordnance 2004.34.16. Custin David R. NAME OF LOBBYIST: (Last) (First) (M.1) David R. Custin & Associates, Inc. 6401 SW 113 PL, Miami, FL 33173-1083 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) ~ (Zip Code) 305-412-3772 305-412-3773 CustinDRC~DavidRCustin.com .TELEPHONE NUMBER: FAX NUMBER: EMAIL: 1. LOBBYIST RETAINED BY: ~ LD(dE-~~EC C~MS'il2VG1~A/, Lam(' NAME OF PRINCIPAL/CLIENT: U~ol~t~-Ec' r©~s't ~2yc~t^.r., !v, ~G c - 4~~/ ~~ Pawl-r:,~,~•c-- F~ D rir-~h~r-ti B~~f~l ~-FC 3 3>?~ BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) ~ti~-lam S4a-33aS __ ~~~~-sGn _ ~~.-,~ FAX 3 out a Corporation, Partnership or • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~N/'~c tv sc~ RSSE~/ ~l4 (c)) • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: J~1 AS's-~~~ ~NG. n.SPECIFIC LOBBY ISSUE: ITB # 17-09/ 10, ROW Infrastructure Improvements, Neighborhood No. 12- S. Pointe Phases III/IVN Issue to be lobbied (Describe in detail): iii. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to clay code sectjon z~a2(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(aH4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be tobbied.) A FuU Name of Individual Title B An Financial, Familial or Professional Relationshi City Manager & administrative staff None Mayor atuH~~ ~i~3,3r'l~~j~~ypn Comm Wolfson: design ~ printing; direct mail; prof. services 5Z =h ~d Z I n ~ . ~ ~= Comm Expositor design & printing; direct mail; prof. services ~5'f RATE OR OTHER): i. i A) LOBBYIST DISCLOSURE: (Required) $ 15,000 flat rate retainer ' _ • B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): W 15 OOO flat rate retalrier - (Requtn3d). w ~ 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": I I_Ye~ No: Are you lobbving on a eresent or aendina bid for goods eauipment or services, or on a present or pending award for goods, eauipment or service? 2) Pursuant to Miami Beady City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes t / INo: Are you tobbving on a pending application for a Development Agn3ement with the Citv or application for change of zoning map designation or change to the Cfir's Future Land Use MeD? i 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 wrporation 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. nNo; Are you reoresentino anot-for-profit comoration or entity without special compensation or reimbursement. . Y. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of PrincipaUClient: VI. LO BYIST IDENTIFICATION Produced ID~ ~hsi_e ~ ~./ ~:•y~_ Form of Identification ^ Personally known {Lobbyist) Vlt. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Swom to and subscrib~ be ore me This,~_day of t r ~ 200 51gn~ltl7re of Public Notary -State Notarization of Lobbyist's si ature IDENTIFICATION: ~ Produced ID Form of Identifiption `Personally known (Principal) State of Florida, County of Miami-Dade Swom and subscribe be e 1~ This _~day of , 2 'da - ature of Public Notary -State of Fb _-- Notarizatton of Principal's signature , / TO BE COMPLETED B Annual Registration fee: [ ]Yes [ ] No Amount Paid Lobbyist Registration Form received and verged by: F:\CLER\HATllForms;tobbyi ~ kEg:._-;,:,;.,: p...-^.~.cer _Z AFF ONLY ;R # -Date Paid Revised I do solemnly swear t tall oft f of ds ,~pd~r~cR and that I have read or am familiar with the provisions contained in on 2 2 of th ar~af ~y',~i Code and all reporting requirements. t L~.~ 4. : ~~~ I Z ~ Yom/ ~M,~. Cit)r of Miomi Beoch, 1700 Convention Center Orive, Miomi Beoch, Florido 33139, vmw.miomibedchfl.gov CITY CLERK Office CityCierk@miamibeachN.gov Tel: 305.673.741 1 ,Fox: 305.673.7254 LOBBYIST NAME: David R. Custin I understand that no later than Qcbbe~ i st of each xea~, 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. l) Lobbyist Expenditure Form 2) Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted b 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: !'~avisad a2,aaf2ons ... ...