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Graham Penn - Russell Galbut (2) A VC tO I A/\A I B E H City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 16 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. Penn Graham NAME OF LOBBYIST: (Last) (First) (M.1) Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5300 (305) 377-6222 gpenn2lbrzaninglaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Russell Galbut NAME OF PRINCIPAUCLIENT: Southpointe Heights, LLC 2200 Biscayne Blvd. Miami Florida 33137 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305 374-5700 TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] �v • 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 Board ADOrovals for Southpointe Heights. LLC—49 Collins Avenue, Miami Beach Issue to be lobbied(Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4) include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's commencement of service with the city to the present date,stating the general nature of the subject contractual relationship. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied Tanning Department and Building Department Staff None X B, HPB, BOA, City Commission, as necessary* None X Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed. Sec 2-482 Any Financial, Familial or Professional Relationship C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc • IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $445 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $445 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 12endina bid for goods,eauiument or services.or on a®resent or agggjpg award for goods.eauipment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes X No: A®rgvou lobbvina on a pending application fgr a Develon.Dp^t Agreement with_the City or application LQC age of p designation or change to the City's Future Land Use Man? 3) Pursuant to Miami Beach City Code Section 2.482(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 Non Are you representing a not for profit corporation or entity Wathout special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON EEBRUARX 28 OF EACeH YEAR, EACH LQBBXIST BHA 01 1119 THE CIIX CLERK A SIGNED STAT91WEE UNDER OATH, LISIING LOBBYINQ EXPENDIJUIRES, AS WELL 10 agrdElygQ, IN JHE CITY OF IWIAMI BEACH B EXPENDITURES OR l gnature of Lobbyis I do solemnly swear that all of the fore g facts re true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach ity Code d all orting requirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID Produced ID Form of Identification i3 Form of Identification L / � W Uf �✓Personally known(Lobbyist) o a Personally known(Principal) ge VII. SIGNATURE AND STAMP OF NOTARY: L 3 State of Florida, County of Miami-Dade z b 2 w State of Flon , Woo Sworn tam subscribed before me •V Sworn d su fore me DAYAMI AGUTAR OI �,y� This day of (JY\ ,2013 aY t This d of *,- ta��&c-State of Florida ART 0 _� o; My Comm.Expires Mar 16,2015 �'• sion#EE 70292 ature bf Pub ic Notary—State of Florida Sign tore ublic No Inrida Notarization of Lobbyist's signature No rizati of Prin®signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ` Annual Registration fee: [ Yes[ ]No Amount Paid$ MCR# f 'Date Paid t / Lobbyist Registration Form received and verified by: 1P f k_-101 �, Y /w 14A 4-, C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files ontent.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc F:\CLE istration Form.doc Revised 04/27/2012 NVAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida.33139, www.miamibeachfl.gov CITY CLERK Office Rafael E.Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax:305.673.7254 LOBBYIST NAME: Graham Penn I understand that no later than February 28 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, or I am no longer lobbying on that issue or for that principal, 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 sus ended from lobbying until all fines are paid, unless the fi.ne has been appealed t e mi-Dade ounty Commission on Ethics and Public Trust. Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc