Mathieu Picard - 14 La Gorce LLC 69�61:�
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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.
Pickard Mathieu
NAME OF LOBBYIST: (Last) (First) (M.1)
Kobi Karp Architecture & Interior Design, Inc. 2915 Biscayne Boulevard, Suite 200 Miami Florida 33137
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 573-1818 (305) 573-3766 moicardCED kobikarp.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:
14 La Gorce LLC
NAME OF PRINCIPAUCLIENT:
90 Amelia Avenue Coral Gables Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)445-4458 (305)445-4458 tom @uniontitleservices.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: Please see attached Exhibit A.
• 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 and Permitting Issues for 14 La Gorce LLC
Issue to be lobbied(Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2482(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 sub"ect contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
Planning Department and Building Department Staff None X
PB, DRB, 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 comm�ssipge�of gi�y�ersonnel who is
.sou ht to be lobbied as identified on the lobbyist registration form filed. cr`;-= I 'r 3
Sec 2.482(8)Any Financial,Familial or Professional Relationship
None4
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY.FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required)
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): 0( ;7. U D
(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":
l lYes (x)No: Are you lobbying on a present or pending bid for goods.eguinment or services,or on a present or pending
award for good s.eguiQment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
I )Yes fxl No: Are you lobbying on a pending anglicatian for a Development Agreement with the City or app
f2E change of zoning mag designation or change to the City's Futu a 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 wrt h ut spe cw
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.
I 1 Yes fxl No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement_
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYISTS ALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
.OATH, LISTING LOBBYING EXPENDITURES. AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH
EM THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FEED EVEN IF THERE HAVE BEEN_ b10
EXPENDITURES ORCOMPENSATION DURING THE
,j/
Sig a ure 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 B ac ity Code and all reporti d requirements.
Signature of Lobbyist: G
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
( )Produced ID ( )Produced ID_
Form of Identification Form of Identification
( ist)rsonally known(Lobby t� t+�vtA�IRl�TrIi�JO { ersonall known(Principal) �i•�"+eft�,;jf�
VII. SIGNATURE AND STAMP O 9��'��% �1 N
State of Florida,County of Miami-Dade: = State of Florida,County of Miami-DadP� e ;� =
Sworn to ubscribed before me'.;; • ®•® ;Q= Sworn subscrib=db re me_. ; °This day of ,20., • EE s7� : This � ay of ,20 ti�1 , ��=O,
Signature of Public Notary—State of Florida -. .:5��:<< ignature o Public Notary—StTtd of Flon a
Notarization of Lobbyist's signature ' Notarization of Prin al's signature
TO BE COMPLETED BY CITY CLERK'S STAFF O LY /
Annual Registration fee: ( ]Yes['j No Amount Paid$ MCR# A Date PaM L 3
Lobbyist Registration Form received and verified by:
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City of Miami Reach, 1700 Convemiom Center Clove„Mani Ek:ack Florida 33139,vAvw.niamibeachfl gov
CTIY CLERK O ff'ice CityClerk @nian ibeachfl.gov
Tel: 305.673,7411 , Fax: 305.673,7254
LO B B Y IS T N A M E: 1Vlatl>ieu Picard
I understand that no later than February 28th of each year, I mist file the following
fom-� pursuant to Section 2485 of the Man-i Beach City Code, with the City Clerks
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 re istered to lobbN, on has been resolved, I am required
qulred
to 'immediately notify the City Clerk's 0 ffice o f to b b gist %v ithd ra w a 1 in w ritin o .
Pursua nt to Section 2 4 8 5 (d), the C ity C lerk sha 11 notify any lob byist (or principa 1) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2 4 8 5 . 1 , a fine of $50.00 a day sha 11 be assessed for a 11 Statement(s)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami0ade County Commission on Ethics and Public Trust.
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V V. JM17,
Signature: bateJ.
FACLERI$ALL1aF0RMSIL0BBYIST FOR.MS\Lobbyist Registration Form.doc