Carly Grimm - Miami Islands Property LLC 635waltSd-
• MIAMI t 1 -
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 2016 lip ; 5 ¢�i; L_,
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.
Grimm Carly
NAME OF LOBBYIST: (Last) (First) (M.I)
Bilzin Sumberg Baena Price&Axelrod LLP-1450 Brickell Avenue,23rd Floor, Miami, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-350-2352 305-351-2251 cgrimm @bilzin.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:
. • Miami Islands Property LLC
NAME OF PRINCIPAL/CLIENT:
4362 NW 112 Court Dora!, FL 33178
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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: SEE ATTACHED EXHIBIT"A"
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: SE&' ArTrAtA450
II. SPECIFIC LOBBY ISSUE:
cAll-zoning-and-land use matters_regarding-design review foi property-at-1835-W 27th-Street Miami.,Beach—F
Issue to`b'e lobbied(Describe in detail):
lll.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
Design Review Board and Staff n/a 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
IV.DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER):
MIAMI 4978532.1 82291/48340
A) LOBBYIST DISCLOSURE:(Required)$310/hr
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):(Required) $310/hr. _
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 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 jNo: 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.
€ Yes -q 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 BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. OAA �
Signature of Lobb st: Carly Grimm
I do solemnly swear that all of the foregoing fa is 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 Co. a,d all reporting requirements.
Signature of Lobbyist: _ �a / ::�� p,® _ /• ar y Grimm J.1>•r >' r mN-
Signature of Principal/Client: !' •
0. 1•G4 i Ut.t A O
VI. LOBBYIST IDENTIFICATION: • `CIPAL IDENTIFICATION:
€ Produced ID € Produced ID _
Form of Identification Form of Identification
• `
1 o ,•�+;�
€ Personally known(Lobbyist) € Personally known(Principal) ( g r
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VII. SIGNATURE AND STAMP OF NOTARY: 4> CA •
ro 1p0.Y Pp '
: ..,0r� IBIS DIAZ 9 j
State of Florida, County of Miami-Dage. .�. * MYCAMMISSIONitFF111262 Stat- •f F • ida, County of Miami-Dade W °
Sworn to and subscri i d before me ,-"u�y°,`;o� EXPIRES:May24,2018 Sw. / t ;ubscrib ..before me g !
Thi _�. &dayrof�� , 26510 OFF1� Bonded Thru Budget Notary Servkea Thi.. -h say of I 2016.
■
• & ' AL / -' I I I Signature o =•blic Notary—State of 4 '.a Si:nature of Public Notary—State of Florida :i�r'Si Notarization of Lobbyist's signature N 'tarizatio of Principal's signature ?>f�'=.,;' 1- 1 TO BE COMPLETED BY CITY CLERK'S STAFF ONLYY,
Annual Registration fee: [ ]Yes ]No Amount Paid$ s5®- MCR# L(O9 q`6 p Date Paid O 7-1 T[; e
Lobbyist Registration Form receiv and verified by: J Arga--.fr SDK.,vh4
Revised 4/27/2012
MIAMI 4978532.1 82291/48340
•
•
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK OFFICE
Rafael E. Granado, City Clerk CitvClerk@miamibeachfl.gov
Tel:305-673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Carly Grimm
I understand that no later than February 28th of each year, I must file the following forms, 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 Form 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.
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 of each year, 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.
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Signature/ Date:
MIAMI 2964847.1 7000060139
4/21/16
MIAMI 497853 2.1 82291/48340
Exhibit "A"
Miami Islands Property LLC, a Florida limited liability company
1450 Brickell Avenue, Suite 2100, Miami, FL 33131
A. Managers
Javier Sanguino
4362 NW 112 Court
Dora!, FL 33178
B. Ownership
1) PE & US Holding LLC 99%
1450 Brickell Avenue, Suite 2100
Miami, FL 33131
a) P&E Irrevocable Trust 100%
i) Settlor: Gerardo Pantin Shortt
ii) Beneficiaries:
(1) Rosanna Escudero
(2) Daniela Pantin
(3) Gerardo Andres Pantin
(4) Marcel Gerardo Pantin
(5) Natalua Sofia Pantin
2) PE &US Investments Corp 1%
1209 Orange Street
Wilmington, DE 19801
a) Gerardo Pantin Shortt 100%
MIAMI 5024266.1 82291/483 40
Miscellaneous Cash Receipt
CITY OF MIAMI BEACH No.4 09 9 8 8 .
❑ Cash ❑Credit Card �Check# ��
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MCR OPEN For / /..?,,5 C- X :9
Payment Amount: 700.00
MCR409988
(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director .
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Account Number OH °°°° - S'6217 L/
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