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Brian E. Keeley - Baptist Health South Florida MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov City Clerk's Office Tel: 305-673-7411 Fax: 305-673-7254 Office Use Only ANNUAL LOBBYIST REGISTRATION FORM Name: BRIAN E. KEELEY Business Name: BAPTIST HEALTH SOUTH FLORIDA Address: 6855 Red Road, Coral Gables, FL 33146 Office Telephone Number: (786) 662-74.01 Cellular Telephone Number: Email Address: briank @baptisthealth.net If more than one lobbyist, please list: 1) 2) �= c 3) 4) r.. -13 5) `JI e _ 6) f-, t.. w 7) Submit this form to the Office of the City Clerk, along with a check for $500 for each lobbyist. Please make the check(s) payable to the City of Miami Beach. For City Clerk's Office Use Only MCR#: Q (i430 Amount paid: gi V Date paid: 7//c. Processed by: C4 4, La,A.,_ Date: /2 7 /.1-- F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\ANNUAL LOBBYIST REGISTRATION FORM reg.docx miAtvid BEAc H City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Mimi 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 foreseea:bly 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. Keeley Brian E. NAME OF LOBBYIST: (Last) (First) (M.l) Baptist Health South Florida 6855 Red Road Coral Gables Florida 33146 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) Pip Code) (786) 662-7401 BrianK @baptisthealth.net • TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your comer information changes:address,phone,or e-mail address. 1_ LOBBYIST RETAINED BY: Baptist Health South Florida, Inc NAME OF PRINCIPALICLIENT: Reci Baptist Health South Florida,Inc 6855,AeatrRoad,Suite 500 Coral Gables FL 33143 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) • (786)662-7401 BrianK @baptisthealth.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: a l p • • c? Pv • IDENTIFY ALL PERSONS HOLDING.DIRECTLY OR INDIRECTLY.A 5%OR MORE OWNERSHIP INTEREST IN SUICH CnPORATION, PARTNERSHIP OR TRUST: c ILSPECIFIC LOBBY ISSUE: T t Planning Board consideration of conditional use at 709 Alton Road, Miami Beach, FL Issue to be lobbied(Desr a in detail): Ill.CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: C) Pursuant to City Code Section 2482(a)(4)include the commissioner or personnel sought to be lobbied,and whether thelbbttyist 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 Planning Board X Planning Department Staff X Pursuant to City Code Section 2-452(g)Every registrant shall be required to state the extent of any business,financial,familial ar 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 NONE IV_ DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY.FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $° B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $0 (Required). 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 R No: Are you lobbying on a present or pending bid for goods,ectuipme.nt or services,or on a present or pending award for goods.equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ❑Yes 04 No: 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 2-484(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. 0 Yes M No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES,AS WELL AS COMPENSA ION RECEIVED,IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SI-tAL_BE FILED VEN ' RE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. .4. •14 Sign= 'of Lob. I do solemnly swear that all of the •regoin;; facts ar- rue and correct and that I ha - • •r am familiar with the provisions contained in Section 2-482 of the Miami : v.fart e , d .I1 l:•;•rting requirements. Signature of Lobbyist: ,11A.Ji.', 1 Signature of Princ ipal/Cfient: (tL ! f 1 , m11111/mpg VL LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ..,j- A p p — ❑ Produced ID (C p ' N a ® Produced ID _ " o Form of Identification e o P,: Form of Identification c d � - z I!S seasonally known(Lobbyist) IS Si W, L'l PersonatIy Icano�rn(Principal) o W o Ai VIL SIGNATURE AND STAMP OF NOTARY: 9 I 9 t t E 4 E liAl ° vc°� State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade z° Sworn to , d subsortul before me .M'' Sworn and subscribed before me a�,�.w•�`,,,� This._ `` . day of \'�N d1s s Q,dg' Thiso? -.mss• of t1,. ., .. °lay, Mk , rte . . -: lb Signatur •f Public Notary— =to of Florida •m.'•`` Signor ire of Public Notary State of Florida ''- t Notarization of Lobbyist's signature Notarization of Princip'al's signature - -. TO BE COMPLET . 7Y CLERICS STAFF ONLY Annual Registration fee: 1 es r 1 No Amount Paid$ • MCR# 4041 3 0 Date Paid / LI 7 ° fir - Lobbyist Registration Form received and verified by: /� a,v L...-Ii____ , LERI$A6:8. aF®t ;LO DBYIST FO kobt tAaaua!Rvgistration€otrnctec Revised 1/11/2011 • M I AM I BEAC H City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.rnmmibeachfl.gov CITY CLERK Office CityClerk @miarnibeachfl_gov Tel:305.6737411 ,Fax:305.673.7254 • LOBBYIST NAME: Brian E. Keeley I understand that no later than February 28th 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. I 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, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. • Sign iture: Date: • LaRosa, Clara hklaw.com AIan.Krischer From: Alan.Krischer@hklaw.com Tuesday,January 27, 2015 2:45 PM To: LaRosa, Clara Subject: Baptist lobbyist registration Importance: Low Clara, Per our discussions,the CEO of Baptist is Brian Keeley—and all of the entities are not-for-profit corporations except for BHE, which is 100%owned by Baptist Health South Florida (which is a not-for-profit). Alan Alan Krischer I Holland&Knight Partner 701 Brickell Avenue,Suite 3300 I Miami FL 33131 Phone 305.789.7758 I Fax 305.789.7799 alan.krischer@hklaw.com I www.hklaw.com Add to address book V owprofessionalbioarayl_y NOTE: This e-mail is from a law firm, Holland&Knight LLP ("H&K"), and is intended solely for the use of the individual(s)to whom it is addressed. If you believe you received this e-mail in error, please notify the sender immediately, delete the e-mail from your computer and do not copy or disclose it to anyone else. If you are not an existing client of H&K, do not construe anything in this e-mail to make you a client unless it contains a specific statement to that effect and do not disclose anything to H&K in reply that you expect it to hold in confidence. If you properly received this e-mail as a client,co-counsel or retained expert of H&K, you should maintain its contents in confidence in order to preserve the attorney-client or work product privilege that may be available to protect confidentiality. 1 F', ',?...16:;;.,-" ).,,,,._ S1 .r-,. wL City of Miami Beach-Florida Finance Department 1 City Hall 1502713-1 01/27/2015 BR1 T121 Tue Jan27,2015 03:14PM Trans#79-79 7S $850.00 MCRCLERK - MCR-City Clerk * MCR#: 401430 1 ITEM(S): TOTAL: $850.00 Check (305344) PAID $850.00 Have a nice day! Miscellaneous Cash Receipt , t t - U; U,:, , o .11 R CITY OF MIAMI BEACH { No. • �.•q Cash 0 Credit Card ©Che ck# , \ 4 $ t'. i ;; 20. 1 1 r( fi.of '� l� 'r d`.� �'-F'�.,; i' 3�+.J,f '�� ,4,1'e„, r [.:'i`, to / • . Received of ` P Address -, ' " ;." (f e y•� ; f i ' ^, 9- r 67 4 : 61'4, -/.. exeie7 - A 44p-di-- (THIS INFORMATION MUST BE COMPLETED) ..' Office of Finance Director By -\)Y1--- ' f Account Number: - • >,. . y yy�y • f' ,f,1,,,,' GA I. fir�y/ 'lP„ f� [M_ �%; Dept �'�.+ •��`l�= Preparers :.;? • �