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Jeffrey Bercow - David Martin —/9 a s- 15700 Col∎lyt5 I�ey►u T 2.26 if-1 Tra�� tb a1 17), ` A �\ I f ��,i v\ 1 )` v PAL � Office of the City Clerk " 1700 Convention Center Drive Miami Beach, FL 33139 •?EJ!6 O%T 26 P 305.673.7411 I LOBBYIST REGISTRATION FORM i ! 'i' 1,,L .0 L 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 City Code Chapter 2, Article VII, Division 3, entitled "Lobbyists," for additional information. Instructions: Please complete all sections of this form and submit the completed form, with the applicable fee,to the Office of the City Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form. The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs. Separate registration forms shall be required for each principal represented on each specific issue. I. LOBBYIST INFORMATION: Bercow Jeffrey NAME OF LOBBYIST (Last) (First) (Middle Name) Bercow Radell & Fernandez 200 South Biscayne Blvd., Suite 850 Miami Florida 33131 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5300 jbercow @brzoninglaw.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: David Martin NAME OF PRINCIPAL (Last) (First) (Middle Name) Terra Group 2675 S. Bayshore Drive Miami Florida 33133 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)416-4556 dmartin @terragroup.com PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code Section 2-482(c): • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: David Martin • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Please see attached - III. ISSUE TO BE LOBBIED: Describe with as much detail as is practical, including but not limited to a specific description where applicable of a pending request for proposal, invitation to bid, or public hearing number. 'Development Approvals and Permitting Issues, including, but not limited to the Design Review Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or Committees, if necessary,trelating to th'e-property-located-at-7925:8700 Collins Avenue and226_87 Terrace, Miami Beach, Florida-73 • IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City personnel sought to be lobbied,and whether the lobbyist has entered into any contractual relationship(paid or unpaid)with said City Commissioner or City personnel from 12 months preceding such commencement of service with the City to the present date,stating the general nature of the subject contractual relationship. Full Name of Individual and Contractual Relationship(If yes,explain) YES NO Title of Person to be Lobbied Staff for the Planning Department, Building Department None X Public Works and City Commission, PB, HPB, BOA None X 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. List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance'of impropriety: None V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a contingency fee is prohibited pursuant to City Code Sec. 2-485.3): $625 per hour The following five(5)questions MUST be answered: 1) Pursuant to City Code Section 2-488, entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _Yes xNo: 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 City Code Section 2-490, entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes xNo: 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 City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481)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 city clerk as required by this section,but shall not be required to pay any registration fees. _Yes xNo: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement? 4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. Yes xNo: Are you providing only scientific, technical or other specialized information: appearing as a representative of a neighborhood association without special compensation or reimbursement or representing a not-for-profit based organization for the purpose of requesting a grant without special compensation or reimbursement? 5) Pursuant to City Code Section 2-482(a)(4), a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particular service before lobbying the City Commission at a public meeting. _Yes xNo: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle?If yes,please list the incumbent member(s)of the City Commission: If yes,you must also orally disclose such particular service before lobbying the City Commission at a public meeting. VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECED ' CALEND• - EAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGA, 4 TO LOB: . ' STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPE If_ DURI G ) . T I PERIOD.1 U , 7 Signature of Lobbyist: Date l O/)_5• / // 7 I do solemnly swear or irm that :II of the f• -going facts, statements, and disclosures in this form are true and correct, and that I have read or am fa "r--r with t • o isions cont-' ed in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code a,d - repo ' .7-• Firemen -. Signature of Lobbyist: Date /0/2,S1/i Signature of Principal: e/-� fir Date It I b I I. I VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: ,, n PRINCIPAL State of ;MI .611. I State of florióCi County of: gmfol " ` County of: 1'1 I u,rn 1 'p o Sworn to(or affirme And,s,ubscribed before me Sworn o (or affirmed) and subscribed before me this day of UL' V{1- , 2016, by this Vt day of ()MOW- , 2016, by S-41- F-ercOlt/ TDu14 Vail?11 NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID 17 FORM OF IDENTIFICATION FORM OF IDENTIFIC\\\\p��ttISANO��i� Personally o �!Person all nown` �� •.•..cOitli....'2,��i �• f',oc ;Ns Signature of Not!r(Public Sig :tur: of otary • blic =2: °�� P 1 mai am 0 La Q,+2t 1, S-a 9i: ` 9 y Name of No'-- . •_., .Pa' Notary Public State of Florida Name of Notary, Typed, Printed 6y,�/,fin'^OF F��P��``\ °'t, /Hf1u1111 Diana Ramos (NOTARY SEAL) (NOTARY " � Q My Commission FF 207719 10,psiv Expires 04/10/2019 TO BE COMPLETED BY CITY CLERK'S STAFF ONO' Annual Registration fee: [ ]Yes NCI No Amount Paid$ 'S 3(9'OO MCR# 113,q110 Date Paid lm-1b-(a Lobbyist Registration Form received and verified by: AicSOi.) JA-'-v,roa cik F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc Revised 08/18/2016 1 The term"lobbyist"specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings;any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. �'_ ;ti l e A I f. ti c 1 L . - I t City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov Office of the City Clerk Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1, Fax: 305.673.7254 NAME OF LOBBYIST: Jeffrey Bercow 1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement (Statement). In addition to any other penalties that may be imposed as provided in Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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. I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a signed Statement under oath listing all lobbyist expenditures, as well as compensation received, for the preceding calendar year with regard to the specific issue on which I have been engaged to lobby. 2) LOBBYIST WITHDRAWAL Once an issue I have registered to lobby has concluded or I am no longer lobbying on that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk. 3) ANNUAL LOBBYIST REGISTRATION FEE I understand annual egistration of all lobbyists shall be required for each 12-month period comme , ing Oc •.,.r 1 of each y-.r, and the fee for such annual registration shall be $500.•o pursu t, Section 2-4; of the Miami Beach City Code. / / 6/2,s7(b Sign. 'e •.f Lob yist Date F:\CLERISALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Reused 08-18-16 REG.doc SUPPLEMENTARY DISCLOSURE OF INTEREST c 0'3 Interests in 8701 Collins Development, LLC"I Percentage of Interest 8701 Collins Avenue, LLC 100% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in 8701 Collins Avenue, LLC Percentage of Interest Terra 8701 Investments, LLC 50% • c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 8701 Associates 2, LLC 50% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in Terra 8701 Investments, LLC Percentage of Interest NV Collins, LLC 50% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Terra 8701 Investments Holdings, LLC 50% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in NV Collins, LLC Percentage of Interest New Valley, LLC 100% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 New Valley, LLC is 100% owned by Vector Group, Ltd., which is a publicly traded corporation. Interests in Terra 8701 Investments Holdings, LLC Percentage of Interest Terra 8701 IH Holdings, LLC 100% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in Terra 8701 IH Holdings, LLC Percentage of Interest Pedro Martin 50% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 David Martin 50% do Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in 8701 Associates, LLC Percentage of Interest 8701 Associates 2, LLC 100% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 Interests in 8701 Associates 2, LLC Percentage of Interest Stephen Della Sala 100% c/o Terra Group 2665 South Bayshore Drive, Suite 1020 Miami FL 33133 . .. . , . .-:,--/-----,.- . a A. o 8 I.7) '•-Z cr) > ni fz, 13 DJ 0 E -a > 0 ...1 .-.. -4 C) 13 0 0 M 0 = 04 r3. = ID E • 0 iv 0 n ..... z E = c -n • cp _ -, '41 3 0 O > M E 0 .. co c.,,-1E , •• J ) ■•• C -, cp 03 (9) - • CD. 0 . • 0.. 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