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Tod Richard Roy - CI Foundation kick GM r MIAMI B EACH Office of the City Clerk RECEIVED 1700 Convention Center Drive SEP 05 2019 Miami Beach, FL 33139 305.673.7411 CITY OF MIAMI BEACH LOBBYIST REGISTRATION FORM OFFICE OF THE CITY CLERK • 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 INFORMATIONqq: —roc( K. NAME OF LOBBYIST (Last)( (First) (Middle Name) C-bkitookliv I-1 30 c LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 0S-1-1 LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: NAME OF PRINCIPAL (Last)/ (First) (Middle Name) 6-'. 1/4-'049%111 13 0 Ste) 93 4 M��-� � �� ? ,s~ ? PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant to City Code Section 2-482(h)(1)(a): A principal of any corporation, partnership, or other entity who appears as a lobbyist on behalf of that entity,without special compensation or reimbursement for the appearance,whether direct, indirect,or contingent,to express support of or opposition to an item shall register with the Clerk as required by this subsection but shall not be required to pay any registration fees. 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(if none,write N/A): • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST(if none,write N/A): TOcir 9�0� Page 1 of 5 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. < Y., - 3 C C A s r^ g CL 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 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 (if none, write N/A): 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): Page 2 of 5 The following six(6)questions MUST be answered: 1) Pursuant to City Code Section 2-488, entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _Yes do: 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&. o: 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. I-Yes_No: 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-profitcommunity based organization for the purpose of requesting a grant without special compensation or reimbur�ld�! for the appearance. Lilfs 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 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s)for whom the campaign consultant provided campaign consulting services within the past election cycle. See Section 2-491 for more information. _Yes No: 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: _Yes l4 o: If yes, has it been less than 12 months since the elected official(s) whom you provided campaign consulting services was sworn in? 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2-491) 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'o: 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: _Yes_No: If yes, were you promised or did you receive economic consideration in exchange for campaign consulting services? TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[o No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: ---.)/1-'‘r.../J---.)/1-'‘r.../ 57A-14-A.,1Yroi N) F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 Page 3 of 5 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 COMPENSATI 0 G THE REPORTING PERIOD.' Signature of Lobbyist: Date .VS--1)9 I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all epokri• . requirements. Signature of Lobbyist: Date (97. 61 Signature of Principal: w' Date / /r ry I VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL r State of Por i�cti State of tC,/or t e� County of: ,["\(cum -\)u.(At_ County of: 111(4''k 1 - ate Sworn_to (or affirmed)And subscribed before me Sworn to (or affirme an subscribed before me this 5 day of tio ' , 20. 1 , by this C. day of , 2011, by NAME OF LOBBYIST NAME OF PRINCIPA /Produced ID et- L /Produced ID ,FL IN-- FORM t L._FORM OF IDENTIFICATION FORM OF IDENTIFICATION Personally nown Personally Known Si ure of Notary Public Sig ure of Notary Public Name of Notary, Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped JASON SALVATORE ; MY COMMISSION#GG 030527 hFV Pb,h JASON SALVATORE (NOTARY S *= (NOTARY SEAL I J ,fir, EXPIRES:September 14,2020 •, MY COMMISSION#GG 03( :t Bonded Thru Notary Public Underwriters si �:ti,r;;z EXPIRES:September 14,2 :•i �:' • ooqBonded Thai Notary Public Und,.. 'Iters 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. Page 4 of 5 MIAMI BEACH 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: e 6 i�. ,) I 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 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 pursuant to Section 2-482 of the Miami Beach City Code. 4 C i°,, ,77,-/i, Signature of Lobby's Date F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Page 5 of 5