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David R. Custin - Bermello Ajamil & Partners, Inc. N MIA/\Al BEACH w � City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 V 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. Custin David R. NAME OF LOBBYIST: (Last) (First) (M.l) David R. Custin & Associates, Inc. 6401 SW 113 PL, Miami, FL 33173-1083 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-607-8576 N/A CustinDR @DavidRCustin.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: Bermello Ajamil & Partners, Inc. NAME OF a RAj Imil & Partners, , Ste 1000, Miami, FL 33133 Bermel o [[��amij & Partners, Inc. 2601 S. Ba shore Dr. BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-860-3731 N/A LAjamilCc�bermelloaiamll.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: • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5°/ OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: rNIV A LV 1 v� II.SPECIFIC LOBBY ISSUE: Secure payment of past due balance for services rendered by the principal to the city, in accordance with memo of Commission meeting item CM 10/16/2013. 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 City Manager, administration staff, &City Attorney's office None LJ Mayor& Commissioners Grieco & Malakoff Political campaign consulting services All other members of the Commission None 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 Not applicable. AUK F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $4,000 flat rate fee. B) PRINCIPAL'�DSQ �(OF LOBBYIST (REQUIRED). �,�U at rateee 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": Yewo: 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 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Ye�o: 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 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. F]Yeoo: Are you representing a not-for-profit corporation or 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-GOMPENUTION RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEME SHALL WFILE"VEMF7HURE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD T:S CL�- Signature of Lobbyist I do solemnly swear t gall h for goi facts ar rue nd rrect and that I have read or am familiar with the provisions contained in Section 2-482 of th ch it ode a all rti rements. Signature of Lobbyist Signature of Principal/Client: kuja� VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: N Produced ID Produced ID b N Form of Ide Form of Identification 'ee',* P�° UUAM R.HATFIELD .i 1. , A41r COMMISSION EE 844865 Personally known(Principal) _Personally known(Lobbyist) EXPIRES:February 18,2017 %e Bonded Thru Notary Public Underwriters VII. SIGNATURE AND STAMP O State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade Sworn to and subscribed before me Sworn p9d subscribed b e me "•�" •,,,' This _day of , 201 is day o 01 o: Signature of Public Notary State of Florida Sign t re of Public o ary—State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[f ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc U Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc jj 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: Xj 14 o 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 bding 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. A, bbyist, who fails to file the required Statement by April 30, shall be automatically uspen r 10' 9 until all fines are paid, unless the fine has been appealed to the M* i-D un Co mission on-Ethics and Public Trust. �S Z ZQ� Signature D6te FACLER\$ALL\aF0RVIS\L0BBYlST FORMS\Lobbyist Registration Form.doc N- -@ AM IL W LU ' � X W IY Co y o . ILD UL 1. 00 co m ! to c i CL != u L U LL Q a.