HomeMy WebLinkAboutSubmittal-Disclosure of Consideration-Mark A. Siffin 7-29-10Submitted into the public
record in connection with
item SP.3 & SP.4 on 07-29-10
Priscilla A. Thompson
CITY OFMIAMI City Clerk
DISCLOSURE OF CONSIDERATION PROVIDED OR COMMITTED FOR AGREEMENT TO
SUPPORT OR WITHHOLD OBJECTION
The City of Miami requires any person or entity requesting approval relief or other action from the City Commission or any of its
boards, authorities, agencies, councils or committees, to disclose at the commencement (or continuance) of the hearing(s) on the
issue, any consideration provided or committed, directly or on its behalf, to any entity or person for an agreegient to support or
withhold, objection to the requested approval, relief or action. "Consideration" includes any gift, payment, contribgkon,*nation, fee,
commission, promise or grant of any money, property, service, credit or financial assistance of any kind orylugwhaer di=t or
implied, or any promise or agreement to provide any of the foregoing in the future. r— C— 70
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Individuals retained or employed by a principal as a lobbyist as defined in Sec. 2-653, and appearing before Ego -city Cmmi4 or
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any of its boards, authorities, agencies, councils or committees solely in the capacity of a lobbyist and not as thAgWlicanTor owisers'
legal representative are not required to fill out this form. <
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NAME: Mark A. Siffin o P-41
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(First Name) (Middle) (Last Name)
HOME ADDRESS:
CITY
527 E. Di Lido Drive
ress Line 1)
(Address Line 2)
STATE: Florida 1-1 ZIP: 33139
FlOME PHONE: 3055356667 CELL PHONE:
EMAIL: siffin@maefield.com
BUSSINIESS or APPLICANT or LNTITY NAME
Maefield Holdings
FAX: 3178050777
BUSINESS ADDRESS.- 250 East 96 Street, Suite 580
(Address Line 1)
Indianopolis, IN 46240
(Address Line 2)
1. Please describe the issue for which you are seeking approval, relief or other action from the City Commission, board,
authority, agency, council, or committee.
Ordinance creating Omni Media Tower regulations and Development Agreement regarding same
and City Square Residential and City Square Retail MUSPs.
2. Has any consideration been provided or committed, directly or on your behalf, to any entity or person for an agreement to
support or withhold objection to the requested approval, relief or action?
X YES F1 NO
If your answer to Question 2 is No. do not answer questions 3, 4 & 5 proceed to read and execute the Acknowledgment. If
your answer to Question 2 is Yes, please answer questions 3, 4 & 5 and read and execute the Acknowledgement.
No.:86543
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3. Please provide the name, address and phone number of the person(s) or entities to whom consideration has been provided
or committed.
Name Address Phone-
a. Venetia Condominium Association, 355 NW 15 Street, Miami, FL 33132 305-373-0557
b.
C.
Additional 1131-neb can be Placed OD a separate page attached to this fonn.
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4. Please describe the nature of the consideration.
The Association requested and I agreed to pay $300,000 to the Association 0
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to assist the Association in its efforts to secure the necessary approvals for a wall
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mural. <
5. Describe what is being requested in exchange for the consideration.
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Support of the Omni Media Tower Ordinance and Development Agreement.
ACKNOWLEDGEMENT OF COMPLIANCE
I hereby acknowledge that it is unlawful to employ any device, scheme or artifice to circumvent the disclosure requirements of
Ordinance 12918 and such circumvention shall be deemed a violation of the Ordinance; and that in addition to the criminal
or civil penalties that may be imposed under the City Code, upon determination by the City Commission that the foregoing
disclosure requirement was not fully and timely satisfied the following may occur:
1. the application or order, as applicable, shall be deemed void without further force or
effect; and cr-
2. no application from any person or entity for the same issue shall be reviewed or t~j E
considered by the applicable board(s) until expiration of a period of one year after the 0
nullification of the application or order.
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PERSON SUBMITTING DISCLOSURE:
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Mark Siffin
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STATE OF FLORIDA
Notary Public. state of Florida
CITY OF
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MY COMMISSION ovary V-111%11111- T PhcoqvnissionDD711372
EXPIRES:
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Print Name
Doc. No.:86543 Page 2