David R. Custin - M-4000 Alton Owner, LLC 0o Y
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MIAMI
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"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:
Camilo Miguel, Jr.
N E4o66N"Xi on`Owner, LLC 119 Washington Ave.,Ste 505 Miami Beach FL 33139
B SINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305) 531-2426 (305) 675-8447
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:
Camilo Miguel, Jr.
• IDENTIFY ALL PERSONS HOI.,p�G,qI CTLY OR ND ECTLY,A 5% R INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: IVIaST"PrO erg Investor Iq EtItOWNERSHIP
u.`SPECIFIC LOBBY ISSUE:I
Redevelopment of the 4000 Alton Road property and board approvals.
Issue to be lobbied(Describe in detail):
---------------------------------------------
ul.;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
Mayor& Commissioners Grieco & Malakoff Political campaign consulting services
All other members of the Commission None 91dT 4i
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial o�ofessional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city'persgnnel wtao is
sought to be lobbied as identified on the lobbyist registration form filed.
CA.) _i t
Sec 2-482(g)Any Financial,Familial or Professional Relationship j
-Not applicable.
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $30,000 flat rate fee paid in installments
B) PRINCIPAL'�,_ R$JErpF�tLOBYISTCOMPENSATION):
(REQUIRED). � eI ee
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 lobbvinq 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":
,F]Ye� 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.
7Yezk 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 WE ENS N RECEIV E CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEmg SHALL BE D EVEN IF THERE HAVO BBSN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERICCL-
Signature of Lobbyist
I do solemnly swear tha all of the for g fac ar true and rrect a e for am familiar with the provisions contained
in Section 2-482 of the ' each y Code n repo ' g re men .
Signature of Lobbyist: 11,oir
Signature of Principal/Client:
By Ma ew Aft-r,Authorized Signatory of M-4000 Alton MGR,LLC,Manger of M-4000 Alton Owner,LLC
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID C�Z, 61-a-s-Z Produced ID
Form of Identification Form of Identification
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Personally known(Lobbyist) Personally known(Principal) a•".5,030
CD
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L)S co SIGNATURE AND STAMP OF NOTARY: U)m `o N
O S O V N'y 1
to of Florida,County of Miami-Dade State of Florida,County of Miami-Dade a'Q E o
Z -N o orn to and subscribed before me _` Sworn an subscribed before me o 0.a
M o day o � ,201_ This L day of ✓. ,201Y Z L)2 w
aQEH , I
:s O`V.a ¢�`• ot
z 0 2 nature of Publi of -State of Florida Signature of Publ' of -State of Florida
N arization of Lobbyist's signature Notarization of rincipal's signature i'r ��!
ON
Z
' 'o` TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
;01V, P ual Registration fee: [ ]Yes[V]No Amount Paid$ .3' MCR# Date Paid Ii
byist Registration Form received and.verified by: IVY
F:\'�LF!2\$ALL\aFORWS\LOBB'I iS i FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33134,www.miamibeachfi.gov
CITY CLERK Office
Rafael E. Granodo, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: David R. .Custin
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 2-4485 (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 2-48.5.1, 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
app iami-Dade County Commission on Ethics and Public Trust.
12 Y
Signature: Date:
FACLERULUaFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
r. MERCHANT COPY
CITY HALL CASHIER OFFI
1700 CONVENTION CNTR DR
MIAMI BEACH,FL 33139
11J13J2014 1331:41
Merchant ID: 000000005148978
Terminal ID: 02013135
275202450886
CREDIT CARD
VISA SALE
CARD# )OOO00000000(7331
INVOICE 0024
Batch#: 001398
Approval Code: 04217G
Entry Method: Swiped
Mode: Online
- Tax Amount: $0.00
SALE AMOUNT $350.00 .
CUSTOMER COPY
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