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Michael W. Larkin - Nicolas Brocherie 4 /\AIAMI BEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM r^ Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourag6-the sag4,'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 thec.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 and emptgyee engaged in lobbying activities. The term"Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. `; 7 Larkin Michael W. -- NAME OF LOBBYIST: (Last) (First) (M.I) 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 mlarkinpbrzoninalaw.corn TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Nicolas Brocherie NAME OF PRINCIPAL/CLIENT: 2121 Lucerne Avenue Miami Beach Florida 33140c' BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip(iode) (305) 753-1119 C/' r. PR 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: _ --1-7 -7�3 • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST FN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: Development Board Approvals for 2121 Lucerne Avenue, Miami Beach, Florida 33140 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 arson'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 Planning 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(g)Any Financial, Familial or Professional Relationship r f7 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 lobbying on a present or nendina bid for goods,eauinment or services,or on a present or Ben=award for goods,gauipment 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: Are you lobbying on a pending application for a Development Agreement with the City or application fQ[change of zoning ma D_desianation or change to the City's Future Land Use Map? 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 No* Are you regresentina a not-for-Drofit cornoratioaor entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 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 ME THE PRECEDING CALENDAR YEAR A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and porrect and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Cod n I e orti requirements. Signature of Lobbyist: Signature of Principal/Client VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: � E Produced ID a _Produced ID c o N Form of Identification S o ° 8 Form of Identification c r',- m gg C w "i LiJ L C)xp WWOO !='� � LU Personally known(Lobbyist) (Z!2.rsonally known(Principal) c 0 Cc� C,> w� VJ 0 va W cC a VII. SIGNATURE AND STAMP OF NOTARY: X cc State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade Sworn to n subscribed before.me =�4°•' (•��= Sworn an subscribed before me ' •' �� ,2013 '''•o°�,. �;:�,� This y-o#� G � 013 %,,do...,,fi�r• Tbis--6�ay-Of� euuoe �roz 8te;;,` Signature of Publi "Notary Florida Signature of Pubic Nota ate of lodda Notarization of Lobbyist's signature Notarization of Prin sign sig ure TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ Yes[ ]No Amount Paid$ 3SD 00 MCR# 315"Wan Date Paid �1 Lobbyist Registration Form received and veri -e y: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Regi xa I Formrevised 5 30-2012.doc rt( l 1 F:�CLE istration Form.doc Revised 04/27/2012 MIAMIBEACH 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: Michael W. Larkin 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 suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami ade County Commission on Ethics and Public Trust. Signature: ate: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc