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John C. Portman III - Portman Holdings, LLC • 1_4 hiegi 014 MIAMI BEAC City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 331392015 , PR 23 drl"i 9: 2G LOBBYIST REGISTRATION FORM CITY C L_ t;,; Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the assa e, defeat or Y P P Y P P 9 P 9 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. Portman III John C NAME OF LOBBYIST: (Last) (First) (M.I) Portman Holdings, LLC 303 Peachtree Center Ave. NE. Ste 575.Atlanta,GA. 30303 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 404.614.5252 404.614.5500 Info @portmanholdings.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: Portman Holdings, LLC NAME OF PRINCIPAUCLIENT: 303 Peachtree Center Ave. NE. Ste 575.Atlanta,GA. 30303 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 404.614.5252 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: CEO: Ambrish Baisiwala • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Portman Family Investments, LLC; John C. Portman IV;Ambrish Baisiwala n.SPECIFIC LOBBY ISSUE:1 Development of a Convention Headquarter Hotel adjacent to the Miami Beach Convention Center 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 Mayor and City Commissioners,City Commission,City Manager and Staff, Convention Center Advisory Board,Planning Director and Staff,Planning Board, _ one Design Review Board,Board of Adjustment,Procurement Director and Staff,City Attorney and Staff. 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 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) Salaried Employees B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): Salaried Employees (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 x 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": x Yes_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 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. Yesx No: 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 AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED . +' - • RE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobby! t I do solemnly swear that all t - 1 regoin• acts 'true and correct and that fhav= -d or am familiar with the provisions contained in Section 2-482 of the Mia, i Be: y C.-`- an.' I reporting requirements Signature of Lobbyist: %�� i;-- ----low, / ft, •Signature of Principal/Clie VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID ■ Produced ID Form of Identifi```;'NAaA44/°/'A® Form of Identi;;one 0111/4,' X Personally known(Lobbyist) •.04,01:°,41% ��1p X Personally known(Prin aiNi t N�►�!�"le"e, • • assloH•� VII. SIGNATURE AND STAMP O m?;•�►Rr A- N Q® O AOTA91- IN Q State of Florida,County of Miami-Dade S T o o:,'/BL\C' State of Florida,County of Si �DadliBL‘G ; ('3 Sworn t.$and subscribed before me 'i •••ToeFR 6,2!)..••O e� Swgr and subscribed befoS *„. o40 Q� This I T day of tt ,2015%Cw•••••°° c,42$ .Thist tfu. day of d 'ie� M.,�,4(7 �L t°°°//Bni,°�� kCr �'��ioV NT`f,,�v%`. ignatu e f Public Notary—State of Florida • ature ,:f P bi Notary—State of Florida otari n of Lobbyist's signature Not . 'in of Principal's signature TO,BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ 4es[ ]No Amount Paid$ 5 t'”' MCR# yo-544'7") Date Paid ylZ3//5- Lobbyist Registration For received and verified by: /' _ F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration�torm.dcc Revised 01/22/2014 • F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc •_. ... MAM1BEACH 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: John C. Portman III 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 t e required Statement by April 30th of each year, shall be automatically suspend om bbying until all fines are paid, unless the fine has been appealed to the Mia 1 - • Cou ty Commission on Ethics and Public Trust. '-*gal .. IF I-q- t 6- Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc _ b. .' . {-, `,1t- 134 Miscellaneous Cash Receipt ' , .; -,i, . ;... js t' i i-: jt,.:1q .) Q 1 10 iJi. CITY OF MIAMI BEACH ._ , - _''' No. El Cash ❑Credit Card Check# 7O ,SbI 02 S 5 s' --' t 1 _/„,1 23 2015_. Received of 3O n 04r,A ”". 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