Michael W. Larkin - Ben Shmul.MIAMI
BEACH
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.
Larkin
Michael W.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow, Radell & Fernandez, P.A. 200 S. Biscayne Blvd., Suite 850
Miami
Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 377 -6231
TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY
Ben Shmul
(305) 377 -6222 mlarkinna brzoninglaw.com
FAX NUMBER: EMAIL:
NAME OF PRINCIPAL /CLIENT:
Insite Miami Beach , LLC 1825 Main Street, Suite 235 Weston
BUSINESS NAME AND ADDRESS (Number and Street) (City)
(305) 377-6238
Florida 33326
(State) (Zip Code)
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:
Development approvals — 1825 Collins Avenue
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
HPB, BOA, PB
None
Planning Department staff
None
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City administration
None
* Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside bE:a?public:7 ear4ng setting.
° ❑ Produced ID
Form of Identification
G/Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $ 445.00 per hour
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 445.00 per hour
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 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 X No: 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 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 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 clerk as required by this
section but, shall not be required to pay any registration fees..
❑ Yes X No: Are you representing a not - for - profit corporation or entity without special compensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST 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 COMPENSATION DURING THE
REPORTING 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 all reporting
requirements.
Signature of Lobbyist:
Signature of Principal /Client:
LOBBYIST IDENTIFICATION:
e of Florida, County of Miami -Dade
rn to and subscrib be ore me
s �O 2 0 1 2 - - t �1
1+Si nature of Public Notary — State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
❑ Produced ID
Form of Identification
+2'5ersonally known (Principal)
State of Florida, County of Miami -Dade
nd subscribe d befiore me
This C) day of r t \ , 2Q i
r
nil
Signature of Public otary — State of Florida
Notarization of Principal's signature
FOR CLERK'S
Annual Registration fee: [ ] Yes [ ] No Amount Paid
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Lobbyist Registration Form received and verified by: Entered By:
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach; Florida 33139, www.miamibeochfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fox: 305.673.7254
LOBBYIST NAME:
\ GIrtaLR_ Lakin
I understand that no later than February 28th of each year, I must file the following
form, 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 and Compensation 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.
Pursuant to Section 2 -485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2- 485.1, a fine of $50.00 a day shall be assessed for all Statement(s)
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, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed t94 M. mi -Dade County Commission on Ethics and Public Trust.
Signature:
F: \CLER \$ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc