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Wayne Brackin - Baptist Health South Florida, Inc (LA - tvisdAmiBEAcH oa 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. Brackin Wayne NAME OF LOBBYIST: (Last) (First) (M.I) Baptist Health South Florida 6855 Red Road Coral Gables Florida 33146 • BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 662-7111 WayneB @baptisthealth.net TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your conracr information changes:address,phone,or e-mail address. II. LOBBYIST RETAINED BY: Baptist Health South Florida, Inc NAME OF PRINCIPALaCLIENT: Baptist Health South Florida,Inc 6855 Read Road Coral Gables FL 33146 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786)662-7111 WayneB @baptisthealth.net TELEPHONE NUMBER: . FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation.Partnership or Trust[Section 2-482(e)] • 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: -6-41C-4 ILSPECIFIC LOBBY ISSUE: C. c Planning Board consideration of conditional use at 709 Alton Road, Miami Beach, FL Issue to be lobbied(Des rite in detal): Iw_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 - - Planning Board X Planning Department Staff X 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(g)Any Financial,Familial or Professional Relationship NONE • VI IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $0 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $0 (Required). The following information must be answered: 1) Pursuant to Miami Beath City Code Section 2-488 Entitled Prohibited Campaign Contributions By Lobbyists On Procurement Issues': ❑ Yes Dil No: 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 2-490 Entitled Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ❑Yes NI No: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoning map designation or chancre 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 IAI 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 COMPENSATION RECEIVED,IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE El-7: N NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. / i / JiL./ L.Abod ` . Si= .'fin?of Lobb st _ 0 I do solemnly swear that all of the foregoing facts ar true nd correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beams i t ; -. an I re rting requirements. /0 / 4, Signature of Lobbyist: . O / ir , ' Signature of Principal/Client: YL LOBBYIST IDENTIFI ATION: / PRINCIPAL IDENTIFICATION: ❑ Produced ID 0 Produced ID b 'o c" Form of Identification Form of Identification c�°, In '• Personally known(Lobbyist ZIT'.43 •• ersonally known(Principal) i A VIL SIGNATURE AND STAMP OF NOTA" 4E4, ill &.- $o . " oa EWE State of Florida.,County of Miami-Dade F State of Florida,County of Miami-Dade —1 `e- e Sworn to a .' subscribed before me g t° o' Sworn an subs i -before me O o 0 ci Z� s� This day of t1 ram . ,20$ v This day of _ z a�. 4 ioNe ts afaitt- .44 var.Ic • 14-1,,,,-, Si atur ' Public Notary S'-te of Flan. fl Signatur Public Notary a of Florida �(7":7_111/ _ gn rY— ' ,,110'6'S g �'— :g'4A14 0_ Notarization of Lobbyist's signature $.5., �' Notarization of Principal's signature ''i i,, 0:; ,,/,,?:::• IIIIIIINI� TO BE • CETED BY CLERICS STAFF ONLY Annual Registration fee: I Yes f 1 No Amount Paid$ grO MCR O/�a,(� Date Paid f /24 11— Lobbyist Registration Form received and verified by: FfERIt L a1ORKS1,LOBBYISTFORSI,t b 1st Annual Regis aa Dom, Revised 1/11/2011 LaRosa, Clara From: Alan.Krischer@hklaw.com Sent: 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 toadoress book j Vi_wprofessional b•opaphy 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 • I AM teity of Miami Bch, 1700 Convention Center Drive,Miami Beach,Florida 33139,vwvw.miamil eachfl.gov CITY CLERK Office OtyC erk@miarnibeachfl.gav Tei:305.67374 11 ,Fax:305.673.7254 LOBBYIST NAME: Wayne Brackin 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. 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, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. /09)77, t (' -Signature: Date: w• tin 5` _rl:W. fit3 r City of Miami Beach-Florida .. Dinar?ce Department 1 City Hall 1502713-1 01/27%2015 BR1 fill Tie Jan27,LG15 G3:15PM Trans#83-. 3 83 $850.00 �=SCRCLERS� - NCR-iii, Clerk MiR#: 401426 S ITEM(5): TOTAL: $850,00 Check (305343) PAID $850,00 Have a nice day! MMAiscellaneous.Cash RQ-� /� ipt "�y 6; �,(� , Vd� j.°�,Jb� �,. k'�- ,�@'.i:'� �?".��1`.; ,:ai�e.iCF. , , . :CITY`.OF'llll�hlMI.BEACH I F°T -s ,0 [�Credit Card ©.Ctieck# 3 C .$ . .Gash __ _ 2. ,• .. -, d . a tG 0 a•L. . ' ' '• " ' •--- .. - : . /...,-/---.1 ' -. - / : --,--, .-._ -f P' �.. ,, i e i,; . ........ 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