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Michael Larkin/Joseph W. Blountm MIAMBEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM 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 Ordnance 2004-3435. Larkin Michael W. NAME OF LOBBYIST: (Last) (First) (M.I) Bercow, Radell & Fernandez P.A. 200 South Biscayne Blvd., Suite: 850 Miami, Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 377-6231 (305) 377-6222 mlarkin@brzoninglaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Joseph W. Blount NAME OF PRINCIPAL/CLIENT: 2535 Lake Avenue Miami Beach FL 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 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: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Redevelopment of 2535 Lake Avenue Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship Planning Dept., HPB, BOA, Planning Board, City Commission None ~ .~~~~Q ~J,r~~'~~~ 3 .11~ [[,J y , IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAB RATE OR OTHERt A) LOBBYIST DISCLOSURE: (Required) $ 375.00 oer hour B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 375.00 cer hour 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 X No• Are you lobbvinq on a present or cending bid for goods equipment or services or on a present or vending award for goods, equipment or service? 2) Pursuant to Miami .Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes X No: Are you lobbvinq on a pending applicationfor a Develovment Agreement with the City or apvlication for change of zoning map designation or change to the Citv's Future Land Use Man? 3) Pursuant to Miami Beach City Code 2-484 (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 representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ 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 BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. ./1 /ICI /r ,. w Signature 9f Lobbyist A ~ o LL m o ~ ~ °~ ~~~'~c~ a~~ ~~~ g z°i~i~w Y ~~~ °w . s~` I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. „ ,~ ~ ,, Signature of Lobbyist: Signature of Principal/Client: d VI. LOBBYIST IDENTIFI ON: ^ Produced ID A / Form of Identification 11~ Personally known (Lobbyist) VII. SIGNATURE AN STAMP OF NOTARY: State of F i ,County of i i ad Swor scribe e Thi c~y of Si a of Public Notary -State of Florida otarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: L ~ ~ °o N " ~ ~~~ ~ z Produced ID ~~^' "'~~ ~U~° ~c° Form of Identification ~ U p a Y ~ ^ Personally known (Principal) zw~ o~ Y ¢ ~ ~ m V ~ (' ~~ ~~Yco. wUo.~~ 11V'~ d'~/ Y -~ m ' State of F.lerida, County of e m a z ~ Sworn and subscribed b fore me t/ This ~ day of , ~OD d }, O E adr ~~n l" O Signature of Public Notary -State of Florida Notarization of Principal's signature FOR CLERK'S USE ONLY '~ ©f Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid Lobbyist Registration Form received and verified by: Entered By: mac. ? F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIS'r FORM OS.da Revised 12/08/04 G~/ J'~~ Y ~, City ai Minmi Beach, T 7DE} Convention Center Drive, Nliomi Beoc?~, Fiortdo 33 T 39, www.mfomibea~hfl,~av CiiY CLERK OLfice CityCleric~momibeachfi.gow lei; 345.b73.74T t .Fax: 345.b73,7254 LQBBYIST NAME: l G"`-`"'~ V~/~ ~/1 I understand that no later than t?t#ober 1st of each year, 1 must file the fallowing farms, pursuant to Section 2.4$5 of the lV~iami $each City Code, with the City Clerk's Office far all active lobbying issues. 1) Lobbyist Expenditure Farm 2j Disclosure Farm Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-0ade County Cc~mmissian an Ethics and far code violation evaluation. In addition, once an issue I have registered to lobby an has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist Withdrawal in writing. ~~ ~g, ~~~ Signature: Date; ;~~~~~ :~ ~~?rt ,t,°lrr3