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Monika Entin - Williams-Sonoma, Inc.
t toot( pica I City of Miami Beach Office of the City Clerk .� n `' 1700 Convention Center Drive, Miami Beach, FL 33139 p r r : LOBBYIST REGISTRATION FORM i.! j i _ .` ., -' lc, 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. Entin Monika NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell &Fernandez, PLLC, 200 South Biscayne Boulevard, Suite 850, Miami, FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-377-6237 305-377-6222 MEntin(a BRZoninaLaw.corn TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: Joan Fitzaerald Hill, VP Real Estate for Williams Sonoma. Inc. NAME OF PRINCIPAL/CLIENT: Williams-Sonoma, Inc., 3250 Van Ness Avenue, San Francisco, CA 94109 BUSINESS NAME ANU AUUKESS (Number and Street) (city) (State) (Lip Uode) 415-421-7900 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:Publically traded on the NYSE as WSM. • IDENTIFY ALL PERSONS HO I G DIRECTLY O,R INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: •A)Vr. II.SPECIFIC LOBBY ISSUE: Dr gpm;ent Approvals_and Permitting Issues,j.cluding, but not limited to the Historic Preservation Board, Design Review Board, Planning Board, Board of Adjust em nt;Land Use Development Committee, City Commission, and any City Workshops or Committees, if necessary, relatina to the propertu located at91 Michigan Avenue:Miami each—Florida. Issue to be lobbied(Describe in detail): Ill. 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 Staff for the Planning Department, Building Department, None. X Public Works and City administration, PB, HPB, BOA, None. X DRB, City Commission, and Mayor 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\clerhat\A PP Data\Local\Microsoft\Windows\Tern ora rY Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration , Formrevised 5-30-2012.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$425.00 per hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $425.00 per hour (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 XNo: Are you lobbvina on a present or pendina bid for aoods.eauipment or services.or on a present or pending award for aoods.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 XNo: Are you lobbvina on a oendina application for a Development Aareement with the City or application for chance 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 X No: 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 E B Th_f_ER_MED_ItsLG CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR •►i' ► _ •► D ► -0; :. : •D 1111rq._ Signature of Lobbyist I do solemnly swear that all of the fore.•.ing-facts-are-true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Be-- • Code as• - resorting requirements. Signature of Lobbyist: S \s\ ignature of Principal/Client:II VI. LOBBYIST IDENTIFICATION: // PRINCIPAL IDENTIFICATION: / •`5 ti's. Produced ID d I:� ' "Produced ID CA Vr�V I 1znc -DA") Form of Identification =�9�••••,m; ` Form of Identification YN_Personally known(Lobbyist) o 'ersonally known(Principal) o 4' VII. SIGNATURE AND STAMP OF NOTARY: y -0. m a X Cl State of Florida, County of Miami-Dade 0 '0• r State of Flori•- County of Miami-Dade • "' r- Sworn and subs► ibed before me Sworn to a d subscribe• before me -n y This - .;i;y;f I P ,2et5" Olio o gu ° Z p This day of ,2015 /Pi cn• NO 4M+ACk Signat,re of N��ary-State of Florida N d Signature of Public Notary-State o •rida Notarization 7 obbvist's signature _ _ — Jotarization of Principal's,signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes No No Amount Paid$ 3S 0 c CO MCR# KOet I L7 fo Date Paid bq'OS`fb Lobbyist Registration Form received and verified by )wrS a iV 4Ta CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§ 1189 .<_,,, —1—,e-T„. . --.. a•VvV..a:�C�•e-s,,..c.c:c...c.._v. Q ._a.• .-.a_aC ._a. CSC.a.c.c,..as.:a,.'!ci C!a./a _c,<_aC�c_cw..s.•.-a, ..a.. A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of Cali rnia ) County of , an 3c° ) On Motrdil 31, Al(a before me, LWfle IbtresA. rD4 ) V Date Here Insert Name a d Tjtl 4of the er personally appeared & SA .f l Name( gner(sf who proved to me on the basis of satisfactory evidence to be the person whose name(,sf is/ap'e subscribed to the within instrument and acknowledged to me that I /she/t ey executed the same i hy�/her/thiir authorized capacity(i ),and that Ay Ii(s/her/tlir signature( on the instrument the person r, or the entity upon behalf of which the person acted, executed the instrument. Y P P I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. LAURIE THERESA BROWN •,._V,; ,, Commission # 1990296 WITNESS my hand and official seal. Z _,2:, mY�. Notary Public-California D Z San Francisco County My Comm. Expires Sep 3, 2016 Signatu e OAA— 1'2 /t r:/b1,1---7.-- Signature of Notary Public Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document Title o •e of Document: Document Date: Number of Pa.: : Signer(s) Other Than Named Above: Capacity(ies) Claime• • Signer(s) Signer's Name: Signer's Name: ❑Corporate Officer — Title(s): ❑Corporate Officer — Title(s): ❑ Partner — ❑Limited ❑General ❑ Partner — ❑ Limited ❑General ❑Individual ❑Attorney in Fact • Individual ❑Attorney in Fact ❑Trustee ❑Guardian or Conservator _ tee ❑Guardian or Conservator ❑Other: ❑ Other: Signer Is Representing: Signer Is Repre :sting: ''rr4 4'rr4'y4�,Aas 4�4 4�4.✓'Cwr'�-e74-o"\147-�"4,-,;_e_r,' -�4-rr4�-ervA7,4Sy4 '.4'.4'a 4',d4'y4'er4t✓4�4 ,4S•1(.4,,,,,4,W-,4-r..-M'•r,4'ri4-ar4's4,✓4_ ©2014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907 .. M I AM I BEACH 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: Monika Entin 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 $50.00 a day shall be assessed for all Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the assessed fines after notification. Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the ■■• '-Dade County Commission on Ethics and Public Trust. e-J .4/41 IP Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Miscellaneous Cash Receipt > = g ,,' 4 .I.1 �$ ±� r: '0.1.o- 003 x. CITY OF MIAMI BEACH j ' •No i far Yxl.7r _ _ r.44 Cash Credit Card ¢ Check#:.. : . . . t ,4 $ � r ,3 , w, y: {- 05 20 1 ' = Received of S : C rle 2 ' '- All o f t tz 1. Address u I(3 i A 4 s C:P- ; € VL.vb Sr . 3C)-1, /Ajt1� I_ _-251 C_ For �5� j:�- j ;. "�. �. � ;'. I.S A.t ,, _ . (THIS INFORMATION MUST BE COMPLETED) Office of Finance-Director :I," t�F� , '}J6 r ;Account Number //, 71, Li ,a: , ,:„.•=-1,=7- `�Preparer: .v_ ..; Dept: 1 f_i: EXT: 1 t tip, =,-‘,-,_ __x ..H.. , ,, {r :;:.0-„._,_-YI _3- _ i ...,z a., r :r x i k =cp N (A :. co c) L U O -- i O - CO UMONO CD •• O U = O = Lo ' ' 4 —.0 •— 1 O • t[f C!] O 4- CU >,Cr") L O r -' v O U a--r .- Q O = tD •r LD Q f� U W 1 >, C U C° Ea U U !- U CU U L L I- r = # T U =