George Burciaga - Civiq Smartscapes KF-P --w
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lLIYTice of the City Clerk
1700 Convention Center Drive
Mier-TY Beach FL 33139
305 673 7411
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained whether paid or ndl. by a principal who seeks to encourage the passage. defeat or
modif cation 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 'Nil! 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 sheets) of paper If you have nothing to report in a particular
section, you must write 'cone' or "nia- 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:
BURCIAGA GEORGE
NAME or LOBBYIST Lash IF(rsti (Midde Name)
CIVIC)SMARTSCAPES 430 FORTUNE BOULEVARD MILFORD MA 01757
LOBBYIST BUSINESS NAME AND ADDRESS (Nyrber and Street) (0(ty) (State) Zic Code)
312-300-4740 GEORGE BURCIAGA@CIVIQ.COM
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NLIMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
ANSEL MI JOHN
NAME OF PRINCIPAL (Last) (F rsh (Middle Name]
CIVIC)SMARTSCAPES, 430 FORTUNE BOULEVARD MILFORD MA 0'757
PRINOiPAL BUSINESS NAME AND ADDRESS :Nurnte,a'd Street', (C,t . iState) r,Z( Code)
312-300-4,'40 JOHN ANSELMI@CIVIO COM
PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TEI SPHONE 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(4
NAME 1 CHIEFChILl I CER PARTNER OR BENEF1CiARY GERRY BURNS PRESgDENT
• NAME OF A.LL PERSONS HOLDING DIRECTLY CR INDIRECTC..Y. A5 OR MORE CVINERSHIP INTEREST IN SUCH
CORPORATION PARTNERSHIP OP TRS T CIVIC HOLDINGS LC n,r JMC.; CAPITAL PARTNERS,
125 SUMMER STREET SUITE 1840 BOSTON, MA 02110
III. ISSUE TO BE LOBBIED:
Descrice tri as MUC,h de!<3,1 35 is practical irickuding Lt no limited lc a spe.cifc descriptior where applicable or a pending request for
proposal inkftat on to bid or public hearing number
RFP 2017-074-VVG,
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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
CITY OF MIAMI BEACH 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):
$6,000 00 MONTHLY-6 MONTHS
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_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 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 dc`nition 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 1No: 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, No: Have you provided cam.ai•n con-ul in, services to an in umbent member of the Cit Commission
within the past election cycle?If ves,_please list the incumbent member(sl 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 PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENSATION DURIfilall,RE TING PERIOD.1
Signature of Lobbyist Date
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I do solemnly swear or affirm that al' e fo acts, -tements, and disclosures in this form are true and correct,
and that I have read or am familiar with the provision •ntained in Chapter 2, Art VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code and all reporting =.•'• -nts
/� -CI \ \CA \ n
Signature of Lobbyist 7 Date
Signature of Principal ___Jiiiw Date -s /)?/Z" / '
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of l "1 1 t" IC? State of /41 J S'¢Ce•yvt.f0'TT7
County of (t C IL. : County of V,7 )ifC'5TEK
Sworn to(or affirmed)and subscnbed before me Sworn to(or affirmed)and subscribed before me
this VI day of_ I1/11.1-1 ,20 I l by this IY''day of m L ,20 by
Clfija1(- )U c1a ( R fo,i4 /lid��
E OF LOBBYIST NAME OF PRINCIPAL
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I o a §i_ ature of Notary ub : MI Signature of Notary Public
° A KENNEY
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t Ze of Notary Typed, Printed or Stamped Name of Notary. T .` ri4teemonikalliisai MaasscOussi,
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tenor allOPSTARY SEAL) (NOTARY SEAL) Z�•
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
/nnuai Registration fee: [ Yes( j No Amount Paid S Me'•Ot. MCR# N Tb W I Date Pak 0 5"at 317
I Lobbyist Registration Four received and verified by: j.co,,,'5;Y`- ,01.-i'b i'U.a
IF:',CL:'.`SA.L',aFORMS\LOBBYIST FCRMS`,Lubuyist Registration Form Revised 08 18_16 REG doc Revised O8/18/2O16 i
' The term"lobbyist"spec.iticaily excludes the following persons
Expert witnesses who provide c ity 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
City of Miami Beach. „. { r'lle E;--r: h do 3
Cf-hce of the City Clerk
Rafael E Gronadc, City Cierk
Tel 305 573 741 1 r0„ 305 573 7254
NAME OF LOBBYIST: GEORGE BURCIAGA
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 30'” 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 weil 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 registration of all lobbyists shall be required for each 12-month period
commencing October 1 of each year, and the fee for such annual registration shall be
$500 00 pursua Section 2-482 of the Miami Beach City Code.
Signature o ..byist Date
r .
MANY
City of Miami Beach
1700 Convention Center Drive `
Miami Beach, Florida 33139
www.miamibeachfl.gov
City Clerk's Office
Tel: 305-673-7411
Fax: 305-673-7254 Office Use Only
ANNUAL LOBBYIST REGISTRATION FORM
Name: GEORGE BURCIAGA
Business Name: civic)SMARTSCAPFS
Address: 430 FORTUNE BLVD.. MILFORD. MA 01757
Office Telephone Number: 312-300-4740
Cellular Telephone Number:
Email Address: GEORGE.BURCIAGA@CIVIQ.COM
If more than one lobbyist, please list:
1)
2)
3)
4)
5)
6)
7)
Submit this form to the Office of the City Clerk, along with a check for $500 for each
lobbyist. Please make the check(s) payable to the City of Miami Beach.
For City Clerk's Office Use Only
MCR#: ti l b O N
Amount paid: ASO.oo 60.00 ) Date paid:
Processed by: - ' Date: 05' 31 7
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