2024 Lobbyist Registration Form - Convention Center Hotel and Hospitality (David Martin) DucuSi�n Envelo�ID.96A242d43FC6-020499FS58F6D80B26Et vOnYC j`� �V � �e ���`�`
HJ-�f,t L` �'JS� . �'d1iT /
� � � Office of the C�ry Clark - . ..
7700 Convention Center Onve
Miami Beach, FL 33739 � � � � �
305.673.7411
LOBBYIST REGISTRATION FORM �
Lobbyis� means all persons employetl w reteinea, wtiether paitl or not, by a pnnclpal who seeks b enwu�age�he pessage, tleteal o�
modification of eny ordinarice, rewlution, aciron or tledsion of any wmmissio�r, any ac[ioq decision, recommendation of Ihe City
Manager or any City board a comminee;or any action,decision or recommentla4on ot any City personnel during the tlme perioa of Ne
entire decision-makin9 process on such actbn, decision or recommentlation Net faeseeably will �e �eartl or revlewed by lhe City
Commission, or e Ciry board or commiVee. The term specifcelty indudes the pnncipel as weli as any empioyee engaged in lobbying
activities. The tertn'LobtryiSC has spedfic exclusions. Please refer to Ciry Ccde Chapter 2, Artide VII, Division 3. enfiMeE "Lobbyists'
for additional informabon.
InsUuctions: Please complete all sections of�his form and submit the completetl form,with ihe epplicable fee, lo ihe Office ot the Ciry
Clerie. If you r�eee more space lo complete an ans�r, use a separate sheel(s)of paper. If you have �w(hing to report in a pa�ticular
secfion, you must wnte 'none' or 'n!a' in ihat sec�ioa Any change ro any intormation onginally �tetl, or any adtlitional Ciry
Commissioner or personnel who are also sought to be bbbied shall require thai ihe bbbyist(le an amendment to the registration form.
The bbbyist has a wntinuirg dury lo s�ppty information and amend the forms filed ihroughout Ne period U�at ihe lobbying oxurs.
Separate reqistrelion fams shail be required for each pnncipal represenietl on each specific issue.
i. LOBBYIST INFORMATION:
Carmona, Jacqui
NAME OF LOBBYfSi (Last) (Fl�sry (Mddle Name)
Rubin Tumbull &Associates 401 E Las Olas Bivd, Suite 130-447, Fort Lauderdale, FL 33301
LOBBYISTBUSINESSNAMEANOAODRESS (NumbereMSVeep (Ciry) (5tate) (ZipCotle)
3�5-283-4558
L09BVISTBUSMESSTELEPHONENUMBER CELLULARTEIEPHONENUMBER EMAILADDRESS
11. PRINCIPAL INFORMATION:
Martin,bavid
NAME OF PRINCIPAL (LaSq (Fks[j (Middie Name)
MB Mixed Use Investment, LLC 3310 Mary Street, Suite 302 Coconut Grove, FL 33133
PRINQPALBUSINESSNFMEANDAODRE55 (Num�erantl5treet) (Cily) (Stete) (ZipCotle)
305-507-3150 davidC�terragroup.com
PRINCIPALBUSMESSTELEPHONENUM9ER � CEIIUTARTEIEPHONENUMBER EMAILMDRESS
PursuaM ro GlY CoOe SeUlon 2<82lhN�Ka)� A PmWWa��a^Y�a�^� V�riemliF.�or olher erd�H wAo aP7ears as a bbEyM on bMaq of thal
enMY,mtlrout e1�1a1 ca�Y+e�metlon a rNmW�semenl fu Ne�Oaerance,wTether Girccl.�6iWeQ�rc canWqen�.ro ezPress suPP�of or W Ws�ion lo
an kem shaA ra�ster with Ihe Ckvk az mqu4e4 by ihis wbsectlOn bui shed iot ba reQuketl lo pay ary regisYaUon feos.
If the principai is a Corporetion, Partnership or Trust, the following information MUST be provided
pursuant to City Code Seetion 2-482(c):
• NAME OF CHIEF OFFICER,PAF2TNER,OR BENEFICIARY(if none,write WA): N' �
. NAME OP ALL PERSONS HOLDING,DIRECTLV OR INDIRECTLY,A 5 h OR MORE OWNERSHIP INTEREST IN SUCH
CORPORAiiON,PARTNERSMIP OR TRUST('rf none,write N/A}: DBVId, P2tllO, 8nd JaCkiO SOffBf
Page 1 of 5 �
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111. ISSUE TO BE LOBBIED:
Describe with as much detail as Is pracrical, includFng but not limited to a specffic description where
applicable of a pending request for proposal, Invkation to old, or public hearing number.
Convention Center Hotel and Hospitality _
IV. CITY AGENCIES(INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code 5ection 2-482(a)(4), Iist the City Comm(ssioner or City personnel sought to be
lobbted, and wheMer the lobbyist has errtered iMo any contrectuai relationship (paid or unpaid) wiM
said City Commissioner or City pereonnel from 72 months preceding such commencement of senice
with the Ciry to the presem tlate, stating the general namre of the subject coMrectual relaUonship.
� -- — -._..---------- �
Full Name ot NAlvidual antl � 1 Cont2ctual Relationship(If yes,explain) YES No I
Title of Person to be Lobbied �
�Mayor, Commissioners, and City Staff X
�—_ -
I � �� �
Pursuant to City Code Section 2�82{g), every registrant shail be required to state the ertent of any
business, floancfal, Yamiltal or profassional relationship, or other relationship giving rise to an
appearance of an Impropriety, wkh any cunant CHy Commissioner or City personnel who is sought to
be lobbietl as IdeMifleA on the lobbylst registretlon fortn flled.
List any Business, Pinancfal, Familial or Professional Relationship, or oMer relaHonsh(p giving dse to an
a arance ot im ro rie if none wrRe N/A :
h — —__. _ _
V. DISCLOSE RATE AND AMOUNT Of LOBBYIST COMPENSATION — Be Soeci£c. (Note that a
contingency fee is prohi6ked pursuant to City Code Sec. 2-085.3j:
Page 2 of 5
�ocuSign EnvebpelD�.96A24280.3FC6-420A-99FS98F6D8D825F1
The toilaxing si:(6)quesHons MUST be answered:
1) Pursuent to City Code Section 2-W8,entitktl'Prohibitetl Campagn Contnbutions By I.obbyis[s On Pmcurement Issues':
Yes XNa: a t i ' f r t b
pindina aw8ld/Of pOOl15.MuiUfIMM W SBfVice?
2) Pursuant to Cfty Code Secfion 2d90, entitleC'Pmhibited Campaign ConUibutions By LobOyisls On Real Estate Development
Issues':
_Yes�No: Are ou lobb in on a ndin a IicaHon for a Develo ent A roement with ihe C" or a liwtion
for cha e of zonin ma desi nallon or chan e to the Ci 's Future Land U e Ma T
3) Pursuan[ to Ciry Code Section 2<82�h�, any person (excepl lhose exemp� hom the defini�ion of'lobbyisf as set forth in
Section 2�481)who only appears as e representative o�a noi-tor-pmfit cwporation or entiry without special crompensafion or
reimbursement for Ne appearance,whether direct or intlirect to eapress support of or opposition to any item,shail register with
the cdy clerk as required 6y this section.but shall not be required to pay any regisiration fees.
_YeszNo: Are ou re msen9n a mlfa mfit co roCion or entl withou[ ecial wm nsatian or
reimbursement9
4) Pursuant to City Code Secfion 2-/81, lhe tenn "lobbyist" specifically eacludes Ne foliowing persons: Expetl witnesses wfio
pmvide only scientfic. lechnical orother specialized intortnation or testimony in public meetings;any person who only appears
as a representative of a nelghbortrood association wlihout compensation or reimbursement for the appearence.whether direct,
indirect w con6ngent,to express support of a opposdion to any item:and any person who onty aDPears as a representative of
oohfor-pmft community based o�gan¢ation for the purpose o{ requesGng a grant without sper.iai compensa[ion or
reimbursement for�he appearence-
_Ves yNo: Are ou rovid'n scien6fic hnical ar other ' I f adon a tl s a
reomaenurive of a neiahborhood asaociafion wiMout acecial comceaution ar reimbursement or
reuresemina a nadw-orofit based oraanization for fhe �uroxe o� reauestina a o2nt without
acecial comoensation or reimburse�nt7 .
5) Pursuant ro Ciry Code Section 2d91(1�, rw campagn consultant shall bb6y the Ciry Commission for a period of 12 monMs
foliowing the swearing in ot eny elected offiaal(s)tor wfrom the campaign consultant provitled cempaign m�ulling services
vnthin ihe pas�election cyde. See Section 2d91 kr more information.
_Yes�No: Have ou itlatl cam ' n<onsuHin ice ro an cum nt memGer C Cwnm"s ion
within the oast election cvde?If ves.ol¢ase list Ne incwnbent mem6ertsl of the Ciri Commission:
Yes X No: If ves. has tt been less tiw��12 montha si�e tl�e ebc4tl officiaNsl whom vou urovW W camoafan
— — salsWtMa�sxviwawaaewwnin4
fi) Pursunnt m Ciy Coda Section 2d82(ax41a.. e bhbyist who has wi�hin tbe past xieotion rycle pmvideA rampaiB� r,onsultinp
services to an incum6ent member of ihe Cily Canmission (which lo6byirg activity is not othervnu prohibiled by CoOe section
2-491) shaA disclose such pertiwlar senice on hisfier lobbyist registraGon (ortn and shali a'allY disdose such oeNcular
s rvi e befae lobb i ihe Ci Commi sbn ffi a ublic meetin -
_Yes Y�No: Have vou mwidad eamnaian eonsultina services to an incumbent memher o(tlre CiN Commiuion
vriMin Ne oast elecfion cvcM?If ves olease list the ineumbent mert�beAsl ot tlte C8v Commission:
VesX No: M�ras. wen.vou�oranised or dIC vou roeeiw�ecanomic conaMeratfon in exchalwe for pmoainn
— — <onaWt6wseMceo?
TO BE COMPLETEU BY GtTY CLERK'S STAPF ONLY
00 ^
Annual RegiGratlon fee ��Yea� ]No AmauntPa(lO�S ��Q• MCR� /3s a 1 a OaOe P�itl3 �G
Lobhykt Reylsiratlon Form recelvetl anE ve�illeG by: L M
..,.;. , ....� ,>- Revi�etl03/31/2020
Cy p��v�\ Da,>;s#ea+ren �jSoo Pase3of5
(1� New )ssvos �� 7�J
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VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBVIST SHALL SU9MIT TO THE OFFICE OF THE CITY CLERK A
il['NED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
$,�CENEO FOR THE PRECEDINC CALENDAR YEAR VJITH REGARD TO THE SPECIflC ISSUE ON WHICH THE
i nawnsr ue5 gEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IP THERE HAS BEEN NO
EJ(PENDITURE OR COMPENSATION DURIN6 THE REPORTING PERIOD.'
Signature ot LobbyisY L � �� Date 3/6/2024
` ;
1 Ao solemnly swear or affirm that aN of the fwegomg facts, statements, and disGosures in ihis foim are true arW cortect,
antl that I have reatl or am familiar with ihe provisions corRained in Chapter 2, Art. VII, Division 3, en5tled"Lobbyists" of
the Miami Beach City Cotle and a11 reporting requireme�ts.
Signamre of�oWyisl: � -Y" � Date 3�6/2024
SignatureofPnncipal: ��// L Da[e3�6/2o2a
Vit. NOTARY SIGNATURE AND SERL:
LOBBYIST: ( PRINCIPAL
Siace ot Florida 5w�e or Florida
counry of: Broward county os: Broward
Swom to (or affirmedj and su�scribed before me. Sworn fo (or affirtned)and subscnbed before me,
by means of O physical presence by means ot�physical presence
or e online notanzafion, or¢oMine notarization,
mis �. naymMa«n �n24ny tnis�nayn{ �na�rn 2n2d, ny
Jacqi Carmon2 I David Martin
NAME OF L06BYIST NAME OF PRINGPAL
ProducedlD _ProducedlD
FORM OF IDENTIFICATION FORM OF I�ENTIFICATIUN
XPer�onall�� _ x Per nallyKno � � _ `
. �1�_/1�.T—
C,_\ (7ti.7-%t�
�L.r'����—
Signature of Notary Publ Signature of Notary Pu
511a�� '����at,.�- Chc.��tmc�.c� �al�t-C��dt�.
Name of No[ary, Typed. Printed tamped Name of Notary; Typed, Pnnt Stamped
(NOTARY SEAL) �5���W�R�P4C�de (NOTARY SEAL)�,,,,,,,, ��Q�W���be
Carten.:HH 97E8g7 .✓...,�'y,
��EMP�g:MarCh 27.2027 :R��p`;e� fumm.:HH 378997
�. NderyPoG6c�St#eotFlondz a.�F �7�:��h27,2027
'Thetarm'9obbyist"spe�caAyexGutleslhefotlowingpereons: �� No�2ryPuhGc-$�n¢MFWtqE
Expen vetnesses wfio provide only saentifiq technical or oMer spenai¢ed Informativn or tesiimony in puWic meetings; any person wfio
onty appears as a representative of a neighbort�ootl association v.it�out compensation or reimbursement for the appearence, whether
tlireq. intlirecf or contin9ent, lo express support of o�opposNon to any dem; antl any person who onty appeare as a representative of
not-for-profit mmmvnity based o�ganiza6on !or 1he purpose of raquesGng a gront w+ihoul speciel compensation or reirtbursement tor
the appearance.
Page 4 of S
DocuSign Envelope Ip:SbA24280.3FC6-420VJ`9FS98F6D8p826N
CirydMiam�eeaah. �'W-. .f- Cen:�. � ,!d� on.,ca F u..o _. ....c.:chfl.ys�
Offke o[d�e City Clerk
R�faet E Grenodq City Cle.k ::tyClerk9miamlbeachf�-gov
Tel: 305.6737411, Fox�. 305.673.725a
NAME OF LOBBYIST: �acqui Carmona
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 providetl 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 [he failure of a Iobbyist (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 2S of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyis[ expenditures, as well as compensation
received, for the preceding catendar year with regard to the specific issue on which I have
been engaged to lotrby.
2) LOBBYIST WITHDRAWAL �
Once an issue I have registered to lobby has conduded or I am no longer lobbying on
that issue, I shall immetliately file a Notice of Withdrewal 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 Octo6er t 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.
C_ ��,� —._ 3/6/2024
s�
Signature of Lobbyist Date
.,��ta,H«,��».,Sy�e.�s,��,,,s�am.�,�.,.��n�Fw.,Ra,,..,a.,_„_mAE�du
Page 5 of 5
L .� k..
City of Miami Beach
'700 Convention Center Drive
Miami Beach, Florida 33135 .. � :���� �
www.miamibeachfl.gov
Gity GlerKs Office , ,
Tei. 305-673-7411 ��
Fax: 305-673-7254 � . .. 01fice Use pniy
ANNUAL LOBBYIST REGISTRATION FORM
Name: Jacaueline Carmona
Business Name: Rubin Tumbull 8 Associates, Inc
Address: dm F i Iac Blvd �it 170-44� Fort a�derdale FL '��301
Office Telephone Number: 954-467-3993
Celtalar Telephone Numbee 305-283-4558
Emaii address: )acqui@rubintumbull.com
if more than one/obbyist, pfease list:
�� - —
1j
3)
4)
5)
6)
7)
Submit this form to the Office of the City Ciark, along with a check for 5500 for each
lobbyist. Please make tha check(s) payabie to the City of Mlami Beach.
For Ciry Cierk's Office Use Only .
MCR #: -� �, O _
OV G
Amount paid: S�V• Date paid: 3 0 �
Processed by: �'C / I (. .0 Date:
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� Miami Beach , FL 33139
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O � Reference 1: RCR433210
�. MCR OPEN (MCR)
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