Michael W. Larkin - C1 Bank c/o Trevor Burgess 1 1 I ZO\ `Z.bk\N ,v
MIAMI BEACH
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
21'315 OCT -5 Aid II: 2
LOBBYIST REGISTRATION FORM
'Lobbyist means all persons employed or retained, whether paid or not, by a principal who seek-'16'encoura e,the P assag e;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.
Larkin Michael W.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell&Fernandez, PLLC 200 S. Biscayne Blvd#850 Miami, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-3 77-6231 MLarkin(aibrzoninalaw.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:
Cl Bank c/o Trevor Buraess
NAME OF PRINCIPAUCLIENT:
100 5th Street South St. Petersburg FL 33701
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(727)456-5828 Trevor.Buraess(aIclbank.com
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: Trevor Burgess,CEO
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:n/a
II.SPECIFIC LOBBY ISSUE:
Development Approvals for Cl Bank Palau at 1201 20th Street
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 City Commission, Development None. X
Boards, Land Use Development Committee None. X
and Commission as necessary 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.
None_
, None_
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.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) $ 525/hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED)._ $ 525/hour
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 XNo: Are you lobbvina on a present or pending bid for goods.eauioment or services.or on a present or pending
award for aoods.eauipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes XNo: Are you lobbvina on a nendina application for a Development Agreement with the City or application for
chanae of zonina map desianation or chanae to the City's Future Land Use Mao?
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.
1 Yes XNo: Are you reoresentina 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 BEACI•L
EQ$ 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:
.5:! -------.....0-AtiS
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) Zersonally known (Principal) ,-,. �;
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VII. SIGNATURE AND STAMP OF NOTARY: N.'4, &: .; i,
State of Florida, County of State of Florida, County of I /1 i e.a �:.,,
Sworn to and subscribed before me Sworn and subscri ed before me a ci Q.
This day of , 2015 This l� d of , 015 z_`;..w
lG .,.
Signature of Public Notary-State of Florida Si a ure of Public Not -State of Florida g'
Notarization of Lobbyist's signature Notarization of Principal's,signature 4*.oft
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY?
Annual Registration fee Yes[ No Amount Paid$ `1j MCR_# `' O / Date Paid 10)5/I
Lobbyist Registration Form receiv d and verified by: Ittav4,■./
•
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $ 525/hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $ 525/hour
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 XCNo: Are you lobbvina on a present or pendina bid for aoods.eauipment or services.or on a present or pendina
award for aoods.eauipment or service?
2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
—Yes XNo: Are you lobbvina on a pendina application for a Development Aareement with the City or application for
chanae of zonina map desianation or chanae 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 XNo; Are you representina 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 BEACK
EQB THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIODS •
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 r quirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
o `.4 ..*.'N°
Produced ID `
W 'o��_ 1. Produced ID
Form of Identification il; 1.44_��:=f/ Form of Identification
S ..........°�
/Personally known(Lobbyist) M 33 Personally known(Principal)
71 11 r.4
VII. SIGNATURE AND STAMP OF NOTARY: 5 0 n
z N —
State of Florida, County of M Pith - E.P n a State of Florida,County of
Sworn to and subscribed before me u oz m Sworn and subscribed before me
This day of Set-A015 T o This day of ,2015
o zz
3 p w 1V
Signature of Public Notary- ate Florid co Signature of Public Notary-State of Florida
Notarization of Lobbyist's signature Notarization of Principal's,signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Data Paid
Lobbyist Registration Form received and verified by:
r
M 1AM-I BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachtl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: Michael W. Larkin
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 Miami-Dade County Commission on Ethics and Public Trust.
C \} q Gs
Signature: Date:
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Form revised 5-30-2012.doc
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