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David R. Custin - South Florida Auto Truck Dealers Associationi MIAMI BEACH. i Beach Office of the City of Mlam City y 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. Custin David R. NAME OF LOBBYIST: (Last) (First) (M.1) 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: South Florida Auto-Truck Dealers Association NAME OF PRINCIPAUCLIENT: South Florida Auto-Truck Dealers Association 625_ N.E. 124 St. , North Miami Beach FL 33179 BUSINE S NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305 981-1448 N/A RBaker(cDsfad.net 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: i t - 4_6i..e-J P/2 e:S Voe.,, • IDENTIFY ALL PERSONS HOLDING,DI &OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: ll SPECIFIC L®BSY ISSUE:; - ....... : Secure dates with the Miami Beach Convention Center for future South Florida International Auto Show events to occur at this venue. Issue to be lobbied(Describe in detail): m CITY AGENCIES/INDIVi®UAL$ TO BE L®BBIE®• 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 pr2sent date,stating the eneral 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 Mayor& Commissioners Grieco & Malakoff Political campaign consulting services rV [All other members of the Commission None FILZ 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 ersonnel who is sought to be lobbied as identified on the lobbyist registration form filed. c-,1 . � .l`� s ` P J Sec 2 482 Any Financial, Familial or Professional Relationshipn of applicable. J • F C V e 4� F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Ir7 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $40,000 flat rate fee. () PRINCIPj L'%DIS6LQUffff F LOBBYIST COMPENSATION): REQUIRED UUat rate tee 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 lobbyinq 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": FAre 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 2481 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. �Yewblo: 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 MPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT ALL U FI VEN THERE-"A E BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD Signature of Lobbyist I do solemnly swear th all of the re g cts are true a orr t pnd that I have read or am familiar with the provisions contained in Section 2-482 of the iami Beach ity Co all r rt' S. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: roduced ID r L�/�1 i/e� Lz Produced ID a ,'� Form of Identification v o`do a yc. Form of Identification Personally known(Lobbyist) Q4�20 Personally known (Principal) h qi VII. SIGNATURE AND STAMP OF NOTAR .r,QO�j 4,-j c��°� �.••o<payPGe•-, F yy ;+ -� MARISA A. OSSORAI State of Florida,County of Miami-Dade om�oF�Fhro tate of Flo State of Florida Sworn t d s ribed ore me �g� �oD� worn an , efBRa�m. xpirea Jun 27,2018 Qi� This day o ,2 1_ •••`e`;��",,,,, °c S n#EE 211 Q si o' m 808 a c_ Signature -Public Not -State of F ida-��•., o� Sig ur of Public otary- to of Florida Notarizati n of Lobbyist's signature %,,,;;;;; Not rization of Principal's signature TO BE PLETED BY CITY CLERK'S STAFF NLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ - d MCR# Dat Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\L0BBY1ST F®RMS\Lobbyist Annual Registration Form.doc Q Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc I MAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 3313.4,www.miomibeachfl.gov CITY CLERK Office Rafael E. Granado,City Clerk CityClerk@miomibeachfl.gov Tel:305.673.741 1 ,Fax:305.673.7254 LOBBYIST NAME: David R. Custin 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 FORAM 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 a e h 'am ade Cou scion on Ethics and Public Trust. © 2or Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc i r JE Lu je CL � co j a 1 - ♦i - o 1