Andres M. Arcila - M-4000 Alton Owner, LLC (lobo MI4v4 2�,FL
BEAcH City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM `� � �ty pi;
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.
Arcila Andres M.
NAME OF LOBBYIST: (Last) (First) (M.I)
Naturalfical, Inc. 6915 Red Road, Suite 224, Coral Gables Florida 33143
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 321-2341
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, ore-mail address.
I. LOBBYIST RETAINED BY:
Camilo Miguel Jr.
NAME OF PRINCIPAUCLIENT:
M-4000 Alton Owner, LLC 119 Washington Avenue, Suite 505 Miami Beach Florida 33139
BUSINESS 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 HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNFRSHIP OR TRUST.Sep attachment
II.SPECIFIC LOBBY ISSUE:
Development Board Approvals for 4000 Alton Road. Miami Beach. FL
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
Planning Staff, PB, HPB, BOA, DRB, Commission None 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
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$ (t. 90D 1Y-er NiA/
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): `0.O-A �/
(REQUIRED).$ V9( Ike '
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: L L- • _ . ... •I . • I __ II , . . :I .•I . .•. • . . . .: -. . 11 - , . - - r • . GI . - : 1 1 . . - , ..•1 ..
Sward for goods.eapipment 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: sire you lobbvina on a Wending application for a Develooment 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.
_Yes X No; Are you representing a not-for-profit corporation or entity without special compensation or reimbursement
V. SIGNATURE UNDER OATH:
•\ : : . : • - ■ L : - ■ • - - ■ L = ■1 TO THE : • . B L 11. ► ►-li ►.
• 1 ■ ■ •= ► • _ I • i� - ► _ • , i : • , OF MIAMI BEACI{
E�Q�pp - - k ■ HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD, -
-I
_� •
Signature of Lobbyist
I do solemnly swear that all of the fore g 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 ode and all reporting requirements.
Signature of Lobbyist: •
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
.k.411
Produced ID Produced ID L# e
Form of Identification orm of Identificati• • /
A 6 Oy—o13--80--Oecc-0 z .
Personally known(Lobbyist) Personally known(Principal) 8 n
VII. SIGNATURE AND STAMP OF NOTARY: gill
State of Florida, County of Miami-Dade State of Florida, Cour0 of Miami-Dad f°'' a
Sworn to and subscribed before me wor and subscrib=•;before me • $
This day of ,2015 This . 2? day of • 4/(f ---,2015. N
Signature of Public Notary—State of Florida Sign ublic Notary ate of Flo • a
Notarization of Lobbyist's signature Nota ' tion of Principal's signature
TO BE COMPLETE' BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [� ]Yes[ ]No Amount Pai $ 0 MCR# O'�I 'i Date Paid ���/�
Lobbyist Registration Fo received and verified by: /,■
1
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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):
(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 lobbvina on a present or pending bid for goods.eauipment or services.or on a present or pending
award for goods.eauioment 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 Agreement with the City or application for
change of zonina map desianation 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:
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 BEACIj
EQB, THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE _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 and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: 2 '
:y amm o •Igue, r., 're •en o • r■ • on • •, , •anager o • 1 1 1 •lton Owner,LLC
VI. _.._LOBBYIST...IDENTIFICATION:._._. PRINCIPAL.IDENTIFICATION:..
N N
Produced ID I Produced ID 5 p
Form of Identification I Form of Identification '
ads
to
Personally known(Lobbyist) x Personally known(Principal) lb
VII. SIGNATURE AND STAMP OF NOTARY: g .. E
State of Florida,County of Miami-Dade j State of Florida,County of Miami-Dade ` 0
Sworn to and subscribed before me I Sworn and subscribed before me z
This day of ,2015 This 26th day of August 2015 ���'��►��•,
474 'te 'ere-
Signature of Public Notary—State of Florida Signature of Public N —State of Florida • _. ;.�'
onn.+`
Notarization of)..obbvist's signature Notarization of principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ i MCR# Date Paid
Lobbyist Registration Form received and verified by
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I F:\CLE istration Form.doc Revised 04/27/2012
MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, 4 www.miamibeachfl.gov
CITY CLERK Office
Rafael E.Granado, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 ,Fax:305.673.7254
LOBBYIST NAME: Andres Arcila
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, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the iami-Dade County Commission on Ethics and Public Trust./5-`
441 460/Signa . 140 Dat :
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SUPPLEMENTARY DISCLOSURE OF INTEREST
Beneficial Ownership interests In M•4000 Alton ®vvner, LLC
Alicia L. Jarrett 730
100 S Pointe Dr.#3804
Miami Beach, FL 33139
Camilo Miguel, Jr. 24%
119 Washington Avenue, Ste. 505
Miami Beach, FL 33139
•
Miscellaneous Cash Receipt ;:.i. i o, , t- ;2:A;-t: , , 001 121
CITY OF MIAMI BEACH .c.j. r t'� ts,,; t_. 4071.'5 $2,le-50.U&)
ra a1 b No -s U i `i ab,
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In Cash El Credit Card Check# O r`016 il $ ZO&2,
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Received of ?14-t /'e( A j e L f 1,1 i C .A1 L , J 4 i 406 t.l.$ -1:13-
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Address A44
For __;6O;.:;4!-I&:� 1?.c c 1 / I z 1 Z L?vi£,L i
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(33' 5 1 ? A0044 t
(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
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Account Number: ° )1- 9600 2)61` 14`7'
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