Jackie Mansfield - South Beach Tristar, LLCr r'1
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MIAMI BEACH d
City of Miami Beach Office of the City Clerk \10 k►�
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.
Mansfield Jackie
NAME OF LOBBYIST: (Last) (First) (M.I)
South Beach Tristar, LLC 140 N. Federal Highway, 2nd Floor, Boca Raton, FL 33432
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
561-241-6336 imansfield@tricaa.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 Beach Tristar, LLC
NAME OF PRINCIPAUCLIENT:
Same 140 N. Federal Highway, 2nd Floor, Boca Raton, FL 33432
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
561-241-6336 (William Weisman. Registered Agent)
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: David Edelstein,Managing Member
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: David Edelstein—60%;Jackie Mansfield—20%;Robert Futterman—20%
II.SPECIFIC LOBBY ISSUE:
Development approvals and permitting issues for Miami Beach Community Church located at 1620 Drexel Avenue
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
Staff of Planning Department,Building Department,and Public Works Department None. X
B,HPB,BOA,City Commission,as necessary None. X
Pursuant to City Code Section 2482(8)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 .J I j_3 C') ;
None
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
/hour 4,�
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): 4o Cj� dIA t
(REQUIRED). /hour
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: aM y.2u lobbvina on a present or pending had 12r goods.eauigment or services,or on a present or pending
award for aoods.eguigment 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 lobbvina on a pending application for a Development Aareement with the City or application for
change of zoning map desianatio(I 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 representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
OIL'FEBRUAR_Y 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
MR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD.
Gem. Ati-
Signature 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 Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
Y
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: O
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Produced ID Produced ID ) 'v
Form of Identification Form of Identificatiot u, N y
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Personally known(Lobbyist) " Personally known(Principal) �j o
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VII. SIGNATURE AND STAMP OF NOTARY: a'. Z = E
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State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade a m
Sworn to and subscribed before me Sworn a subscribed before me z
This day of , 201_ T is day of ,201
Signature of Public Notary-State of Florida g ature of Pub!K Notary-State of.WoodaA4t-I A
Notarization of s!r ature Notarization of. signature
TO BE COMPLETUQ y�CITY CLERK'S STAFF NLY /
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ J!0 --MCR# Date Paid �O
Lobbyist Registration Form received and verified by: Revised
F:\CLER\$ALL\aFORMS\LOBBYISTFORMS\LobbyistRegistrationForm.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 'LL//l'f (Aa*e,_)$ /hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). $ /hour
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 lobbyina on a Dresent or oendina bid for aoods.eauiument or services.or on a present or nendina
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":
_Yes X No: Are you lobbying on a pending application for a Development Agreement with the City or application for
chanae 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.
Yes X No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
914 FEBRUARY 28 OE EACH YEAR, EACH LOBOYISI SHALL SUBMIT TO THE C
OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH
EM TH9 PRECE12ING CALENDAR YEAR, A SIAIEMgNT SHALL BE EILED EN IF THERE HAYE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD.
Signature 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 Beach City Code nd all reportin requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before me
AThi _da y of 2 This day of ,201,,�,, BRISEIDAC.LERO MY COMMISSION#DD 987853
ature of Public Notary—State of EXPIRES:May 23,2014 nature of Public Notary—State of Florida
Notarization of Lobbyist's signatte Bonded mN Notary PubOc Undervv�ters tarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and veri ed y: Revised 0112212014
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I
MIAMI BEACH
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: Jackie Mansfield
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, 2014, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
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Signature: Date:
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