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Ronald . Bergeron, Jr. - Bergeron Land Development, Inc. MIAM] 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" as specific exclusions. Please refer to Ordinance 2004-3435. jvx_01 9-rov) , -. /q- NAME OF LOBBYIST: (La (First) (M.I) Inc, 0 46f L B SIN S NAM AND ADDRESS N ber and Str et (City) State) (*Zip Code �� 3 I o TELEPHONE NUMBER: FAX NUMBER: E AIL: PleaseYnoti 'ti'iis'offlc®,ilf' a `our:contactlnformadon chan ies aldress hone or:e=mail;adclress�` '" D I. LOBBYIST RETAINED BY: Rie e/'4f? C. S� wal. L 3,j NAME RI_NCIPAUCLIENT: BU S N D A�� (Number an Stre t) ity (State) • (Zi Code) TELEPHONE NUMBER: F NU ER:(Optional) EMAIL ptional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2=482(c)] • NAME OF CHIEF OFFICER,PARTNER;OR BENEFICIARY: Q(LQ A& 9zw J • IDENTIFY ALL PERSONS HOkOING, IRECTLY OR INDIRECTL ,A 5% R MORE OWNERSHIP TER ST IN UCH C RPO TIO PARTNERSHIP OR TRUST: I Al. 1*401 OF 1-- IlcJP��if�� iwL ��' ��SV Issue to be lobbied(Describe in detail): Ill.`Chi�1GENC1ES/1I DIVIDUA�L'S TO E L,.OBBLED: 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 llto be lobbied I AA !!I . 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 r\ F:ICLERI$ALLIa FORM SILOBBYIST FORMS\Lobbyist Registration Form.doc _ Co o zz (� 1 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) /UW 666696 1re &15d.. B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): 41,2� 5aGue(REQUIRED). [-1!�i� 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": _YesyNo: 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 Section 2-490/Enti "Prohibited Campaign Contrib ion By Lobbyists On Real Estate Development Issues": YesNo: Are ou lobb in on a endin a lication evelo ment A reement ith th Cit or application for than a of zoning map designation or ch9hae t6 the Cit s Future Land se Ma 3) Pursuant to Miami Beach City Code Section 2 2(h) ny person(except thos exempt f om the definition of"lobbyist"as set forth in Section 2-481 above)who only appe rs as representative of a no-for-profit torpor "on or entity without special compensation or reimbursement for the app rance,�vhether direct, or ind' ect, to a ress s p ort of or opposition to any item,shall register with the clerk as required y this sept�on but,shall not be equired to ay any re istration fees. I _YeXNo: Are you re resentin not-for-profit or at or entit witho s ecial m ensatio or reimbursement. V. SIGNATURE UNDER OA . ON FEBRUARY 28 OF EA;H EAR /ACH LOB YIS VAL0SUBMIT/01THE C Y CLERK A S GNED ST EME U DER OATH LISTING LO BBYIN E PENDI URES AS L O PENS ION RE IVED IN THE ITY OF IA A FOR THE PRECEDING CALENDA YEA A STATEM S A E FILE EVEN IF HERE HAVE EN NO E PE ES OR COMPENSATION DURING T REPORTING PERIOD). / V Si ure f yist I do solemnly swear th t II f th fo g/fts are tr a cc rect and that I e read or am li ith a provisions contained in Section 2-482 of the a i Be ch itd all r orti r uir ment Signature of Lobbyist: Signature of Principal/Cli it:\ �K � /I N�INV VI. LOBBYIST IDE TIFIC A I VCIPA E IFICATION: _Produced ID _ ID Form of I ntificaN %%Illifjoo�// Form o ntification Q\\\.TEDD(/e i/i�� q ��111illllllffj _t-OoPersonall known(Lobb ist% Q•�'•••��• � _Personal) known(Principal) �� PPR��•TED /� VII. SIGNATURE AND STAMP�F ••� Y 2q?ors •% s `*�� •••� '•O��'�i�� State of Florida,County of Miami-Dale*1 sr iiEf 0541 State of Florida,County of Miami-D Sworn to and subscrib before me Sworn and subscri ed before me e4l � s This�� ay of P�,20% ••.• �ncOL,. This day of ,20 Q541 / ••...•gap ��,�oe� Signat of Public Notary—State of Florida Sign re of Public Notary—State of Florida /1� !!M I11eN`��, Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY dual Registration fee: [ ]Yes[' ]No Amount Paid$ M C R# T hate Paid r Lobbyist Registration Form received and verified by: f�.CjP%;ALL\a1PORMSXLOBBYIST FORMS\Lobbyist Annual Registration Form.doc �evised 11/18/2-3 F:\CLER\$ALL\a FORM S\LOBBYIST FORMS\Lobbyist Registration Form.doc AAAMIBEACH Vty o¢:'A lami Beach,1700 Convention:Center Drive,,Miami Beach,Aar&331:39;www.miamibecchH:gov CITY'CLERK Office Rafael`.E.Granada,City Clerk City Clerk Qmiamibeacfiflgov 'Tel:;305.673:7411 ,Fax:305.673.7254 LOBBYIST NAME: 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 activer 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 C un Commission on Ethics and for code violation evaluation. In addition, on a an i sue I have registered to lobby on has been resolved, or I am no longer lobbyi g on t at issue or for that principal, I am required to immediately notify the ity Cler s Offi a of lobbyist withdrawal in writing. P uant to ectl 2-4.85(d),the C ty Clark shall notify any lobbyist(or principal)who f Is to timel tIl a Statement an - In. addition to any other penalties which may be I posed as rov ed In Section 2 5.1,a fine of$50.00 a day shall be.assessed for all tdtemont(s) fil d after the due date. The City Clerk shall notify the Miami-Dade unty Corn I sion on Ethics an Publl Trust of the failure of a lobbyist(or principal) le the Sta nt or pay the a sense as after cation. y lobbyist, ho falls to file th requir d S to nt by April 30,shall be automatically span dad lobbying until 11 fines rep , unless the fine-has been appealed to o IIIIiamI- do ounty Comml ion on th nd Public.Trust. nature Date F:ICLERI$ALL1aF0RMSIL0BBYIST FORMSlobbyist Registration Form.doc