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Angel A Pallin - Mount Sinai Medical Center NI o -S r,�w /dle, �202E® �� C.e Ott�. RE It A ib? Cm Office of the City Clerk JAN 2 CE 1700 Convention Center Drive 6 IVu2 Miami Beach, FL 33139 CITY OF MIAMI BEACH 305.673.7411. OFFICE OF THE CITY CLERK 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 "Lobbyist' 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: Pallin, Angel, A NAME OF LOBBYIST (Last) (First) (Middle Name) Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL 33140 LOBBYIST:BUSINESS NAME AND ADDRESS (Number and Street) (City) . • (State) (Zip Code) 305-674-2777 angel.pallin@msmc.com LOBBYIST BUSINESS TELEPHONE NUMBER' CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Santorio, Gino R. NAME OF PRINCIPAL' (Last) (First). (Middle Name) Mount Sinai Medical.Center, 4300 Alton Road, Miami Beach, FL 33140 PRINCIPAL BUSINESS NAME AND ADDRESS • (Number and Street)• (City) (State) (Zip Code) • • 305-674-2777 , gino:santorio@msmc.com PRINCIPAL BUSINESS TELEPHONE NUMBER. ..: • • CELLULAR TELEPHONE NUMBER EMAIL ADDRESS • • rAinirnic©Tj :`^' 10I s °oZItp ,. " CiraU P o :3c obo� .`0�(s7 liOf{aL • •ilirr}`1a soiThreTU(t o� " " ,:\:71 o CS i i >ai�l�nit p R c iIIEf; Si`c o Dent Ci] Q:RMt Cti 07)(MbITRi I)( n Mau aft 'Car la 3cng2 it I '[Iuir Pt1u'(tgenLu1a�t[na l a ft7rp`F�rP/E� iiri .io ei.nz, :. 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): Gino R:Santorio . • NAME OF ALL PERSONS.HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,PARTNERSHIP OR TRUST(if none,write NIA):'N/A. Page of • • 9 • III. ISSUE TO BE LOBBIED: • - Describe with as much detail as is practical, including but not limited to aspecific description where applicable of a pending request for proposal,invitation to bid; or public.hearing number. All aspects of design, permiting and building of a parking garage and cancer center on Mount Sinai Medical Center's Miami Beach Campus. 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 Planning.Department V Building Department • . Administarion • . : Mayor and Commission . • : •• V • • • 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): 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 5 . • : : • . •' 0 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": —Yeslo: Are you lobbvinq 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 41o: Are you lobbvinq 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. V(es_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-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. . \IYes_No: 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.. —Yes4lo: 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: i r2a .� ^t • 12 mon " c: :,el:' o " a ii p.-v" o :o c•--. e: WI . (OM .a =ru ce^ a^_,',o- 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. YesJo:. 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: ., 0^ e ' o p•'o rd-o. d a \tom rec e'o o c c rsnir o I' ere;e '1 'on 6. os en •t .n71l;raolson q • • .TO BE COMPLETED BY CITY CLERK'S STAFF ONLY • AnnualFReglstrati'onlfee:l (c ]JYesv 4LNo) Amount,Paldl$, ' MCSRi#' a .Date)Paidl " • LobbyistFeeglstratl'onlFormlreceivedlandlverifledlby,:, EINCLER\$ALL\aFORMS\LOBBYIS.7PFORMS\Lo6B.yi'stIReglst'ration/FormlRevisedl 034140)REG?doci Revi'sedl03'//111//202D1 • Page3of5 VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED 'STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A ST EMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSATION RI THE O TI PERIOD.' Signature of Lobbyist: c Date January 24, 2022 I do solemnly swear or affirm that all o he foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with the provisio contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all re orti req it Signature of Lobbyist: C Date January 24, 2022 Signature of Principal: Date January 24, 2022 VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of FIo21'DP State of F 1O2ipA County of: Mif 01 t" DAD G'. County of: Nitiril I— DAD Sworn to(or affirmed)and subscribed before me, Sworn to(or affirmed)and subscribed before me, by means of E physical presence by means of l7'physical presence• or❑ online notarization, or❑ online notarization, this day of S$t-OL7/Al2-M , 20??by this 26 day of YPa(1 t.,A' , 20 2-:by • (1C'�EL- C.-ono -R• Spsn+-orto NAME OF LOBBYIST NAME OF PRINCIPAL Produced ID . Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION V Personally Known rsonally Known Signature of Notary Public. . . Signature of NotaryPublic . 9 rY 9 11PclAi i Lcpez P Ias. _L6 z Name of Notary, Typ d:Pi nLed_p4S.tampo — — = Name of Notary,Typed, Printed or Stamped �faY,Pus-.; PAULINE LOPEZ PAULINE LOPE2 (NOTARY'SEAL) �°• Gn .Notary Public-State of Florida (NOT � ►C�' NE — — f• • � kW Commission#HH 132456 t Notary'`� omm �1 ,'; Public:-State of Florida of F;,:^• My Comm.Expires May 30,2025• I Bonded through;National NotaryAssn. ', Commission#HH 132456 , �'?of. My Comm.Expires May 30,2025 I 1 The term"lobbyist"specifically excludes the following persons: I ' Bonded through National Notary Assn. I . 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. = Page4of5 " • City of Miami.Beach;1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamilieachfl.gov Office of the City Clerk Rafael.E.Granado,City Clerk CityClerk@miamibeachfl.gov. Tel 305.673.7411,Fax:305.673.7254 NAME OF LOBBYIST: Pallin, Angel,:A 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 • $500.00. pursuant to Se n.' -48 the Miami Beach City Code. • • r January:24, 2022 Signatur L bb t Date. . F:\CLER1$ALL1aFORMS\LOBBYIST:FORMS\Lobbyist Registration Form Revised•03-11-20 REG.doc• " , • Page 5of5 •