Loading...
HomeMy WebLinkAboutApplication & Supporting DocumentationALEXANDER I. TACHMES, ESQ. PARTNER (305) 347-7341 Direct Telephone (305) 347-7754 Direct Facsimile SHUTTS BOWEN LLP December 27, 2012 Mr. Francisco Garcia, Planning Director City of Miami 444 SW 2nd Avenue 3rd Floor Miami, Florida 33130 RE: Mercy Hospital — helipad application Dear Francisco: E-MAIL ADDRESS: ATachmes@shutts.com We represent Plantation General Hospital Limited Partnership, the owner of Mercy Hospital, 3663 S. Miami Avenue, Miami, Florida ("Mercy"). We hereby apply for an Exception under Miami 21 to construct and operate a helipad on the Mercy campus. We are seeking a helipad on the campus in order to, among other reasons, transport diving accident victims to our hyperbaric chamber and related facilities and to transport patients from the Caribbean region to Mercy. The proposed helipad would be located on the southern edge of the campus, next to Biscayne Bay and away from residential areas. Health Benefits Scuba diving accidents are common in South Florida, given the proximity of this area to the Atlantic Ocean and Biscayne Bay. Victims of diving accidents require specialized and prompt care in order to avoid injury and death. Oxygen therapy is the primary medical treatment for diver accidents. The delivery of oxygen to a patient in a hyperbaric chamber greatly increases the amount of oxygen that can be delivered to the body tissue via the bloodstream. In a hyperbaric chamber, the body is exposed to high levels of oxygen in a special environment in which the oxygen level exceeds the atmospheric pressure. This allows for a high concentration of oxygen to reach the tissue of the body. Mercy has two (2) multiplex hyperbaric chambers on its campus and is able to provide rapid treatment to diving victims. 1500 Miami Center • 201 South Biscayne Boulevard, Miami, Florida 33131 • ph 305.358.6300 • fx 305.381.9982 • www.shutts.com MIADOCS 7098693 1 MIAMI FORT LAUDERDALE WEST PALM BEACH ORLANDO TAMPA TALLAHASSEE AMSTERDAM Mr. Francisco Garcia, Planning Director City of Miami December 27, 2012 Page 2 Since many diving accidents occur in the open water, it is essential to have helicopter transportation available for victims. For a diver who gets injured in the vicinity of Miami -Dade County, the nearest helipad located at a hyperbaric treatment center is miles away. Therefore, the construction of a helipad at Mercy will provide a critical need for diving victims. For that reason, the Miami -Dade County EMS, the Coast Guard and the Divers Alert Network (D.A.N.) all support the construction of a helipad on our campus. The construction of a helipad at Mercy also will enable sick and injured residents of the Caribbean to receive sophisticated medical care. Top quality medical care by specialists is often lacking in the Caribbean region. In those cases, patients need to be flown to Miami to receive the care they need. A Mercy helipad will allow the hospital to treat Caribbean residents who lack adequate medical care at home. Helipad Will Blend Seamlessly into the Community Mercy estimates that its new helipad will generate no more than two (2) helicopter arrivals per month. Therefore, the usage of the new helipad will be infrequent. Moreover, the helipad project is being designed in a manner that is sensitive to the surrounding community. The proposed helipad and the anticipated flight paths of helicopters will be sited away from residential areas. The helipad will be located next to the Emergency Room at the south edge of the hospital campus, only a few feet away from Biscayne Bay and away from Bayshore Drive and residents. Additionally, arriving and departing helicopters will travel over water to avoid flying over residential areas. Based on the above, the noise from helicopters will not have a material adverse effect on residents. Zoning Criteria Our application for an Exception complies fully with the criteria of Miami 21. In particular, the proposed addition complies with the CI district regulations and is designed in accordance with the design review guidelines contained in Article 4, Table 12 of Miami 21. Further, the operation of the helipad will not have a material adverse effect on the surrounding properties. Conclusion The opening of a new helipad on the Mercy campus will provide important health benefits to the community and surrounding residents. And the helipad project will be designed in a manner that is sensitive to the area and community. 1500 Miami Center • 201 South Biscayne Boulevard, Miami, Florida 33131 • ph 305.358.6300 • fx 305.381.9982 • www.shutts.com MIA"NliWcIA918663A/LJDERDALE WEST PALM BEACH ORLANDO TAMPA TALLAHASSEE AMSTERDAM Mr. Francisco Garcia, Planning Director City of Miami December 27, 2012 Page 3 We respectfully request your approval of our application. Thank you. Very truly yours, SHUTTS & BOWEN LLP Alexander I. Tachmes cc: Barnaby Min, Esq., Zoning Director 1500 Miami Center • 201 South Biscayne Boulevard, Miami, Florida 33131 • ph 305.358.6300 • fx 305.381.9982 • wwwshutts.com MI M °cla9186L3A/UDERDALE WEST PALM BEACH ORLANDO TAMPA TALLAHASSEE AMSTERDAM EXCEPTION APPLICATION RECEIVE 0 PLANNING DEPARTMEN 2012 DEC 28 PM I2: 53 PLANNING AND ZONING DEPARTMENT, HEARING BOARDS SECTION 444 SW 2nd Avenue, 3rd Floor • Miami, Florida 33130 • Telephone 305-416-2030 www.miamigov.com/hearing boards Welcome to the City of Miami! This application is intended to serve as a guide in assisting you with our public hearing process. Please feel free to contact us, should you have any questions. The deadline to file the complete application with supporting documents is the last five working days of each month from 8:00 am until 3:00 pm, except on the fifth day, until 12:00 pm. The application submittal date is the date stamped by Hearing Boards' staff on this page. The responses to this application must be typed and signed in black ink. All pertinent and accurate information/documentation; i.e., the plans, reports, exhibits, shall be presented at the time of filing, in addition to the paid receipt. The applicant is responsible for the accuracy of the information contained in the application and all supporting materials. Should you wish, you could bring the materials to our office for review prior to submittal to ensure completeness. You will be responsible, if needed, to bring an interpreter for the English language to any presentation before city boards, committees and the city commission. A valid power of attorney will be required if neither applicant or legal counsel representing the applicant execute the application or desire to make a presentation before city boards, committees and the city commission. All documents, reports, studies, exhibits (81/2x11 ") or other materials submitted during this process will be kept as part of the record. Any documents offered to the Planning, Zoning and Appeals Board and the City Commission, which have not been provided fifteen (15) days before the meeting as part of the agenda materials will be entered into the record at the discretion of the aforementioned Board and Commission. ORDINANCE NO. 11469, CODIFIED IN CHAPTER 2, ARTICLE VI OF THE CITY CODE STATES THAT ANY PERSON WHO RECEIVES COMPENSATION, REMUNERATION OR EXPENSES FOR CONDUCTING LOBBYING ACTIVITIES TO REGISTER AS A LOBBYIST WITH THE CITY CLERK, PRIOR TO ENGAGING IN LOBBYING ACTIVITIES BEFORE CITY STAFF, BOARDS, COMMITTEES AND THE CITY COMMISSION. A COPY OF SAID ORDINANCE IS AVAILABLE IN THE OFFICE OF THE CITY CLERK (MIAMI CITY HALL), LOCATED AT 3500 PAN AMERICAN DRIVE, MIAMI, FLORIDA, 33133. Ordinance No. 12918 states that each person or entity requesting approval, relief or other action from the City Commission or any of its boards, authorities, agencies, councils or committees regarding any issue, shall disclose at the commencement (or continuance) of the public hearing(s) on the issue, any consideration provided or committed, directly or on its behalf, for an agreement to support or withhold objection to the requested approval, relief or action. The Disclosure of Consideration Provided or Committed for Agreement to Support or Withhold Objection Affidavit included in this package must be submitted with the application. The applicant must, at the commencement of any public hearing on the issue, if there is any disclosure to report, read the disclosure into the record. Also, the applicant must supplement the affidavit if there is any new information or additional information to disclose. Copies of City Commission resolutions and ordinances can be obtained at our website through the "Legislative Hub", or for certified copies, contact the City Clerk's Office at 305-250-5360. Applications given to customers do not constitute action from the City of Miami without plans review and written comments from the Office of Zoning. MIA7075842.1 Rev. 07-2012 2 EXCEPTION APPLICATION Please refer to Article 7.1.2.6 of the Miami 21 Code for Exception information. 1. Applicant(s): Shutts & Bowen LLP on behalf of Plantation General Hospital Limited Partnership 2. Subject property address(es) and folio number(s): 3663 S. Miami Avenue, 01-4114-027-0010; 01-4114-027-0011;01-4114-027-0012;01-4114-027-0030 3. One (1) original survey dated within six (6) months from the date of application prepared by a State of Florida registered land surveyor. 4. One (1) original 24x36" plan, signed and sealed by a State of Florida registered architect or engineer showing property boundaries and proposed structure(s), parking, landscaping, etc.; building elevations and dimensions and computations of lot area and building spacing. 5. After Hearing Boards, Public Works, Zoning and Planning initial and date the plans, two (2) 11x17" and one (1) 81/2x11" copies of the original plan, including the survey. 6. Current Zoning Referral and Write -Up signed by the Office of Zoning designee. 7. A clear and legible copy of the recorded warranty deed and tax forms of the most current year showing the present owner(s) and legal description of the property to match the legal description on the survey. 8. A clear and legible copy of the subject property address(es) and legal description(s) on a separate sheet, labeled as "Exhibit A", to match with the current survey's legal description. 9. At least two photographs showing the entire property showing land and improvements. 10. Copy of the lobbyist registration processed by the Office of the City Clerk, if applicable. 11. Affidavit of Authority to Act and the Disclosure of Ownership of all owner —and contract purchasers, if applicable —of the subject property. 12. For all corporations and partnerships indicated: a) Articles of Incorporation; b) Certificate from Tallahassee showing good standing, less than one (1) year old; c) Corporate Resolution or a Power of Attorney signed by the secretary of the Corporation authorizing the person who signed the application to do so; d) Non-profit organizations: A list of Board of Directors less than one (1) year old. 13. Certified list of owners of real estate within 500 feet of the subject property. 14. Original Disclosure of Consideration Provided or Committed for Agreement to Support or Withhold Objection Affidavit. 15. Original Public School Concurrency Management System Entered Requirements form. 16. The subject property(ies) cannot have any open code enforcement/lien violations. 17. What is the acreage of the project/property site? 39.841 Rev. 07-2012 3 MIA7075842.1 EXCEPTION APPLICATION 18. What is the purpose of this application/nature of proposed use? Heliport for Hospital/ See attached Letter of Intent 19. Is the property within the boundaries of a historic site, historic district or archeological zone? Please contact the Planning and Zoning Department on the 3rd Floor for information. NO 20. Is the property within the boundaries of an Environmental Preservation District? Please contact the Planning and Zoning Department on the 3rd Floor for information. NO 21. What would be the anticipated duration of the presentation in front of the: ® Planning, Zoning and Appeals Board 20 MINUTES and/or ❑ City Commission 22. Cost of processing according to Section 62-22 and Section 62-23 of the Miami City Code*: a. CS, T3 (Single -Family and Duplex Residential uses) b. All other uses c. Extension of time c. Exception Permit Requiring City Commission Review d. Advertising e. Mail notice fee per notice f. Meeting package mailing fee per package $ 1,000.00 $ 1,500.00 $ 750.00 $ 2,500.00 $ 1,500.00 $ 4.50 $ 6.00 Fees for appeals of Exceptions shall be collected as a surcharge equivalent to the application fee and advertisement fee and shall be collected from the applicant at the time of initial submission of an application for any Exception. Such surcharge shall be refunded to the applicant unless there is an appeal from an abutting property owner. If an abutting property owner appeals, then the appellant shall pay the applicable notice fee only. if the appellant is not an abutting property owner, then appellant shall pay the equivalent of the original application fee, advertisement fee, and notice fee paid. *Fees over $25, 000.00, shall be paid in the form of a certified check, cashier's check, or money order. Signature Name Barbara Simmons Telephone (305) 415-9488 STATE OF FLORIDA -- COUNTY OF MIAMI-DADE Address c/o Shutts & Bowen LLP 201 S. Biscayne Blvd., Suite 1500 Miami, FL 33131 E-mail ewasserman@shutts.com The foregoing was acknowledged before me this 1 q day of ')eco c-- 20 , by '� � tZ� cc1 T S� mmrk l� r who is a(n) ndivi • ua t• artner/agent/corporation of ' .n . .Q a(n) individua •artiiirship_corporation. He/She i<ersonally know:10 me or who has produced as identification and who did (did not) tjke an oath. ,ipa�n�o�'. LORENA ROMFRO �roo Notary Public S!atr nr Florida a nr My Comm Expires I•r,n 4 2014 Cornmiss'nn # UU 96"149 Rev. 07-2012 ignature 4 MIA7075842.1 EXCEPTION APPLICATION AFFIDAVIT OF AUTHORITY TO ACT Before me this day, the undersigned personally appeared Alexander I. Tachmes, Esq. , who being by me first deposes and says: 1. That he/she is the owner or the legal representative of the owner, submitting the public hearing application as required by the Code of the City of Miami, Florida, affecting the real property located in the City of Miami, as listed on the foregoing pages. 2. That all owners who he/she represents, if any, have given his/her full and complete permission for him/her to act in his/her behalf for the change or modification of a classification or regulation of zoning as set out in the foregoing petition, ❑✓ including or❑not including responses to day to day staff inquires. 3. That the foregoing and following pages are part of this affidavit and contain the current names, mailing addresses, telephone numbers and legal descriptions of the real property of which he/she is the owner or legal representative. 4. That the facts, as represented in the application and documents submitted in conjunction with this affidavit, are true and correct. Further Affiant sayeth not. Alexander I. Tachmes gkIPL, Applicant(s) Name Applicarfft(s) Signature STATE OF FLORIDA -- COUNTY OF MIAMI-DADE The foregoing was acknowledged before me this � day of ^NL f 20 11_ , by Alexander I. Tachmes who is a(n) individual/pr/agent/corporation of S'"1-.,4tr b-9c,,,, Lt,1 a(n) individual/pa ne ` hip/corporation. He/She is perso Iv known to me or who has produced as identification and who did (did not) take an oath. (Stamp) Signature °0'''' -. /0 ETHAN WASSERMAN * (_) * MY COMMISSION # EE 148154 s, ! F EXPIRES: November 22, 2015 ''For no. `° Bonded Thru Budget Notary Services Rev. 07-2012 5 MIA7075842.1 EXCEPTION APPLICATION DISCLOSURE OF OWNERSHIP 1. List the owner(s) of the subject property and percentage of ownership. Note: The Miami City Code requires disclosure of all parties having a financial interest, either direct or indirect, with respect to a presentation, request or petition. Accordingly, disclosure of shareholders of corporations, beneficiaries of trusts, and/or any other interested parties, together with their address(es) and proportionate interest are required. Please supply additional lists, if necessary. Owner's Name(es) N/A - Publicly Traded Company - See Attached Percentage of Ownership Subject Property Address(es) 2. Lisi, all street address(es) and legal description(s) of any property located within 500 feet of the subject property owned by any and all parties listed in question #1 above. Please supply additional lists, if necessary. Street Address(es): Legal Description(s): Barbara Simmons Owner(s) or Attorney Name Owner(s) or Atto4idrey Signature STATE OF FLORIDA -- COUNTY OF MIAMI-DADE •k The foregoing was acknowledged before me this day of '-De Co rc-' r- 20 \ , by r- „fAc \-c:Irc-A -S S‘ rim who is a(n) divid partner/agent/corporation of`-P1aa ;,-4--) 6efw4al A ; 01 a(n) individual rtners tpicorporation. He/She i ow ,to me or who has produced as identification and who did (di • no an oath. i?Wc/23 (� �N w4 LORENA ROMERO Notary Public - State of Florida My Comm. Expires Feb 9, 2014 Commission M OD 960149 Rev. 07-2012 ignature 6 MIA7075842.1 EXHIBIT "A" LEGAL DESCRIPTION: Tracts "A" and "C", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, LESS AND EXCEPT the buildings and improvements conveyed to LHT Miami, LLC, a Delaware limited liability company, by virtue of the Deed and Bill of Sale recorded in Official Records Book 19302, Page 4054, located on the following described four parcels of land: Professional Building: A portion of Tract "A", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of Tract "A"; thence South 54°03'23" West along the Southeast line of said Tract "A" for 306.60 feet; thence North 37°12'04' West for 345.41 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37°12'04" West for 46.77 feet; thence North 52°47'56" East for 7.84 feet; thence North 37°12'04" West for 22.07 feet; thence South 52°47'56" West for 28.68 feet; thence North 37°12'04" West for 14.44 feet; thence North 52°47'56" East for 19.29 feet; thence North 37 ° 12'04" West for 10.71 feet; thence North 52°47'56" East for 8.64 feet; thence North 37°12'04" West for 49.51 feet; thence North 52°47'56" East for 13.80 feet; thence North 37°12'04" West for 8.98 feet; thence North 52°47'56" East for 32.87 feet; thence South 37°12'04" East for 9.00 feet; thence North 52°47'56" East for 37.80 feet; thence South 37°12'04" East for 96.59 feet; thence North 52°47'56" East for 7.22 feet; thence South 37°12'04" East for 46.89 feet; thence South 52°47'56" West for 98.78 feet to the POINT OF BEGINNING. Outpatient Center: A portion of Tract "A", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of said Tract "A", thence South 54°03'23" West along the Southeast line of said Tract "A" for 304.84 feet; thence North 37°12'04" West for 529.73 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37°12'04" West for 147.04 feet; thence North 52°47'56" East for 30.01 feet; thence North 37°12'04" West for 10.90 feet; thence North 52°47'56" East for 33.18 feet; thence South 37°12'04" East for 10.90 feet; thence North 52 '47'56" East for 29.92 feet; thence South 37°12'04" East for 146.98 feet; thence South 52°47'56" West for 9.99 feet; thence South 37°12'04" East for 10.81 feet; thence South 52°47'56" West for 31.11 feet; thence South 37°12'04" East for 21.05 feet; thence South 52°47'56" West for 11.04 feet; thence North 37°12'04" West for 31.80 feet; thence South 52°47'56" West for 40.97 feet to the POINT OF BEGINNING. Cooling Tower: A portion of Tract A, Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of said Tract "A"; thence South 54°03'23" West along the Southeast line of said Tract "A" for 203.34 feet; thence North 37°12'04" West for 316.39 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37°12'04" West for 20.00 feet; thence North 52°47'56" East for 11.92 feet; thence South 37°12'04" East for 20.00 feet; thence South 52°47'56" West for 11.92 feet to the POINT OF BEGINNING. Storage Tank: A portion of Tract A, Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of said Tract "A"; thence South 54°03'23" West along the Southeast line of said Tract "A" for 211.71 feet; thence North 37°12'04" West for 561.06 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37°12'04" West for 12.00 feet; thence North 52°47'56" East for 4.60 feet; thence South 37°12'04" East for 12.00 feet; thence South 52°47'56" West for 4.60 feet to the POINT OF BEGINNING. TOGETHER WITH a non-exclusive easement over the following described land for ingress and egress and utilities, as defined in, and subject to, that Easement in favor of Mercy Hospital, Inc., a Florida corporation not for profit, executed by The Most Reverend Colemen F. Carroll, as Archbishop of the Archdiocese of Miami, dated October 8, 1970, recorded October 15, 1970, in Official Records Book 7003, Page 379: That portion of Tract 4, Vizcaya - James Deering Estate, according to the plat thereof as recorded in Plat Book 34, Page 46, of the Public Records of Miami -Dade County, Florida, described as follows: COMMENCE at the most Westerly corner of said Tract 4, Vizcaya - James Deering Estate, according to the plat thereof as recorded in Plat Book 34, Page 46, of the Public Records of Miami -Dade County, Florida, which point is 15 feet Northeasterly from the intersection of the prolongation Southwesterly of the Northwesterly boundary line of said Tract 4 with the prolongation Southeasterly of the center line of Halissee Street, thence run North 52°47'45" East along the Northwesterly boundary line of said Tract 4, the same being the Southeasterly right-of-way line of South Miami Avenue for 1132.50 feet to the Point of Beginning of the parcel hereinafter described; thence continue North 52°47'45" East along the Northwesterly boundary line of said Tract 4, the same being the Southeasterly right-of-way line of South Miami Avenue, for 40.00 feet to a point; thence run South 37°12'15" East along a line parallel to the Southwesterly boundary line of said Tract 4 for a distance of 1020.00 feet to a point; thence run South 07°47'45" West along a line for a distance of 56.57 feet to a point; thence run North 37°12'15" West along a line parallel to the Southwesterly boundary line of said Tract 4 for a distance of 1060.00 feet to the POINT OF BEGINNING. AND PARCEL 2: Leasehold estate created in that certain Sovereignty Submerged Lands Lease Renewal, bearing BOT No. 130377636, executed by the Board of Trustees of the Internal Improvement Trust Fund of the State of Florida and Mercy Hospital, Inc., a Florida nonprofit corporation, as recorded in Official Records Book 26273, Page 681, of the Public Records of Miami -Dade County, Florida. MERCY Hospital December 27, 2012 RE: Authorization for Barbara Simmons to execute documents on behalf of owner of Mercy Hospital, Miami, Florida To whom it may concern: The owner of Mercy Hospital is Plantation General Hospital Limited Partnership ("Owner"). The corporate general partner of the Owner is HD&S Corp. Successor, Inc. ("General Partner"). I am the Secretary of the General Partner. Barbara Simmons is a Vice President of the General Partner and Chief Executive Officer of Mercy Hospital. Ms. Simmons is authorized to execute all documents on behalf of Owner, including but not limited to all land use applications submitted to the City of Miami. Thank you. Very truly yours, Dora Blackwood Vice President and Secretary, HD&S Corp. Successor, Inc. 3663 South Miami Avenue • Miami, FL 33133 • (305) 854-4400 • MercyMiami.com Hospital Information - Mercy Hospital Page 1 of 1 Find a Physician I Services I Patients Si Visitors I Health Information I For Professionals Hospital Information Home a About Us q Hospital Information 11 Mercy Hospital has been serving the healthcare needs of South Florida for 60 years. As a %% comprehensive healthcare facility, Mercy offers a full range of services to the residents of Miami -Dade county and surrounding communities. A 473-bed acute care facility. Mercy Hospital is accredited by Joint Commission. Mercy is affiliated with over 700 physicians representing 27 medical specialties. Its Centers of Excellence include- The CvberKnifeeD Institute. The Heart Center. the Maternity and Women's Health Center the Miami Cancer Center, the Minimally Invasive Institute the Orthopaedics Institute and the Surgical Weight Loss Center. As Miami -Dade County's only Catholic hospital, Mercy Hospital is sponsored by the t . Sisters of Si. Joseph of St. Augustine, Florida and is affiliated with HCA East Florida Division, an HCA affiliate. Since its Inception In 1950, Mercy Hospital has maintained Its reputation for excellence while following the Catholic tradition of caring for God's people and providing spiritual support. Mercy Hospital is dedicated to providing excellent medical care, while remaining true to Its mission of caring for the physical and spiritual needs of all the people it serves. Follow us on these social networks:Iv112 Call Mercy Hospital at 305-854-4400 HCA East Florida Hospitals Patients & Visitors Services • Classes & Events • Cancer Care • Consult -A -Nurse • Cyberknife • Find a Doctor • Heart Center • International Services • Maternity • Maps & Directions • Orthopaedics • Visitor Intoimation • Weight Loss • Pay MI Onhne Health Information • Conditions A-to-Z • Video Ubiary • ITriage Copyright 6'• ehc cam; All rights reserved I Social Media Disclaimer Terms of Use 1 Privacy Notice Aventura Hospital and Medical Center Kendall Regional Medical Center Mercy Hospital Palms West Hospital Raulerson Hospital Si. Lucie Medical Center West Palm Hospital Salud Intemacional Directions R Wait Time 18 2012 T purposes only. Awards & Accolades Board of Trustees Clinical Research CEO Message Contact Us Our History Hospital Information Maps & Directions Mercy Hospital Medical Partners Mission & Values Newsroom Notice of Privacy Practices Public Notice Sister Emmanuel Hospital Social Media Policy Volunteers 2012 Community Report Quick Links Find a Doctor Classes & Events Directions Our Services Careers (305) 285-2929 ..IFK Medical Center Lawnwnod Regional Medical Cantor Northwest Medical Center Plantation General Hospital Sister Emmanuel Hospital University Hospital & Medical Canter Wesrelde Regional Medical Centei 3663 South Miami Avenue. Miami, FL 33133 Site Map Contact Us Health En Ill iti]C©E http://mercymiami.com/about/hospital-info.dot 12/18/2012 HCA Healthcare I Investor Relations I Corporate Profile Page 1 of 2 HCA Hospital Corporation of Arnericae Print Page Close Window Corporate Profile FEATURED NEWS 12/10/12 HCA Announces Second.ary Offering E-mail Alerts Signup - receive headline stories by email. 12/06/12 HCA Announces Special Dividend of $2.00 per Share and Record and Payable Dates 12/06/12 FICA to Present at Health Care Conference in December WEBCASTS There are currently no events scheduled. CORPORATE PROFILE HCA owns and operates approximately 163 hospitals and approximately 109 freestanding surgery centers in 20 states and London, England. We are dedicated to providing healthcare services that meet each community's local healthcare needs. We seek to integrate various services to deliver patient care with maximum quality and efficiency. Our approach includes focusing on quality; streamlining operations; sharing technology, equipment and personnel where appropriate; and using economies of scale when contracting for medical supplies and administrative services. STOCK AND DIVIDEND INFORMATION HCA Holdings, Inc's common stock is publicly traded on the New York Stock Exchange under the symbol "HCA". You may obtain copies of the company's financial filings posted under the "SEC Filings/Reports" link on this page. TRANSFER AGENT Our Transfer Agent, Wells Fargo Shareowner Services, can help you in a variety of shareowner-related services, including address changes, name changes, stock transfers, lost http://phx.corporate-ir.net/phoenix.zhtml?c=63489&p=irol-homeprofile_pf 12/18/2012 HCA Healthcare I Investor Relations I Corporate Profile Page 2 of 2 stock certificates, account status and other administrative services. You can contact our Transfer Agent at: Wells Fargo Shareowner Services P.O. Box 64874 St. Paul, MN 55164-0874 Phone: 800-468-9716 Certified/Overnight Mail: Wells Fargo Shareowner Services 161 North Concord Exchange South St. Paul, MN 55075 STOCK SPLIT Please see the following information that is intended to comply with the requirements of Treasury Regulation Section 1.6045E-1. Federal Tax Info. Regarding HCA Stock Split CONTACT INFORMATION Mark Kimbrough Vice President Investor Relations Phone: (615) 344-2688 Fax: (615) 344-2266 E-mail: Mark.Kimbrough a;hcahealthcare.com Greta J. Presley Government Relations & Investor Relations Phone: (615) 344-2068 Fax: (615) 344-2266 E-mail: Greta.Presley a HCAhealthcare.com http://phx.corporate-ir.net/phoenix.zhtml?c=63489&p=irol-homeprofile_pf 12/18/2012 111111111111111111111111111111111111111111111 THIS INSTRUMENT WAS PREPARED BY: DAVID A. PEARL, ESQUIRE BUCHANAN INGERSOLL & ROONEY PC 19950 WEST COUNTRY CLUB DRIVE, SUITE 10I AVENTURA, FL 33180 NOTE TO RECORDER: DOCUMENTARY STAMP TAX IN THE AMOUNT OF $687,534.00 AND SURTAX IN THE AMOUNT OF $515,650.50 IS BEING PAID SIMULTANEOUSLY WITH THE RECORDATION OF THIS DEED. Folio Nos.: 01-4114-027-0010; 01-4114-027-0011; 01-4114-027-0012; and 01-4114-027-0030 C.FN 20 1 1. Ri-12822 59 OR Bk 27672 P95 1194 - 1201; (8a9s) RECORDED 05/02/2011 10:39:51 DEED DUC TAX 687,534.00 SURTAX 515,650.50 HARVEY RUVIN, CLERK OF COURT MIAMI-DADE COUNTY, FLORIDA SPECIAL WARRANTY DEED THIS DEED, made as of the �"' day of May, 2011, between MERCY HOSPITAL, INC., a Florida not for profit corporation, whose mailing address is 3663 South Miami Avenue, Miami, Florida 33133, as "GRANTOR," and PLANTATION GENERAL HOSPITAL, L.P., Delaware limited partnership, whose mailing address is c/o HCA Inc., One Park Plaza, Nashville, Tennessee 37203, as "GRANTEE." (Whenever used herein, the terms "GRANTOR" and "GRANTEE" include all the parties to this instrument and the heirs, legal representatives and assigns of individuals, and the successors and assigns of corporations.) WITNESSETH: That the GRANTOR, for and in consideration of the sum of TEN AND NO/100 ($10.00) DOLLARS in hand paid to GRANTOR by said GRANTEE, receipt whereof is hereby acknowledged, by these presents does grant, bargain, sell, remise, release, convey and confirm unto the GRANTEE the following described real property, and rights and interest in real property located and situated in the County of Miami -Dade and State of Florida: Sec Exhibit "A" annexed hereto and forming a part hereof (the "Property"). THIS CONVEYANCE IS SUBJECT TO THE FOLLOWING: 1. Taxes and assessments for the year 2011, and all subsequent years; 2. Covenants, restrictions, dedications, easements of record; restrictions and matters appearing on the Plat or otherwise common to the subdivision; public utility easements of record; or other matters, as set forth on Exhibit "B", without reimposing same; 3. Comprehensive land use plans, zoning restrictions, prohibitions and other requirements imposed by any governmental authority; TOGETHER with all the tenements, hereditaments and appurtenances thereto belonging or in any way appertaining. Book27672/Page1194 CFN#20110282259 Page 1 of 8 TO HAVE AND TO HOLD the same in fee simple forever. THE GRANTOR hereby specially warrants the title to the Property and will defend the same against the lawful claims of all persons claiming by, through or under the said GRANTOR. IN WITNESS WHEREOF, the GRANTOR has hereunto set its hand and seal as of the day and year first above written. Signed, sealed and delivered MERCY HOSPITAL, INC., a Florida not for profit in the presence of: corporation Jn \I;Z;;—(4.. "f 1� (cp.i.kic. (� . I r cat"ate By: Print Name: ft o,C. cas Name: /Lf4 it kL/ / lki,' i, rint Name: Ce s. We.4L STATE OF FLORIDA )SS: COUNTY OF MIAMI-DADE Title: SWORN TO AND SUBSCRIBED before me this day of April, 2011, by u e l .7 1l iun `tas ��'. c en-� % CC: 17 of MERCY HOSPITAL, INC., a Florida not for profit corporation, who is personally known to me ( ) or who have produced , as identification. Name o Notary ( Please Print ) My Commission Expire : Commission No.: 2 /3 (2o)S 2 r ILLY HAHN t^ • 14 my COMMISSION II EE O54oe0 Ti EXPIRES: February 3, 2015 Bonded Thru Notary Public Ihrdereders riltirasraOIOv Book27672/Page1195 CFN#20110282259 Page 2 of 8 EXHIBIT "A" LEGAL DESCRIPTION PARCEL 1: Tracts "A" and "C", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, LESS AND EXCEPT the buildings and improvements conveyed to LHT Miami, LLC, a Delaware limited liability company, by virtue of the Deed and Bill of Sale recorded in Official Records Book 19302, Page 4054, located on the following described four parcels of land: Professional Building: A portion of Tract "A", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of Tract "A"; thence South 54° 03'23" West along the Southeast line of said Tract "A" for 306.60 feet; thence North 37° 12'04' West for 345.41 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37° 12'04" West for 46.77 feet; thence North 52° 47'56" East for 7.84 feet; thence North 37° 12'04" West for 22.07 feet; thence South 52° 47'56" West for 28.68 feet; thence North 37° 12'04" West for 14.44 feet; thence North 52° 47'56" East for 19.29 feet; thence North 37 ° 12'04" West for 10.71 feet; thence North 52° 47'56" East for 8.64 feet; thence North 37° 12'04" West for 49.51 feet; thence North 52° 47'56" East for 13.80 feet; thence North 37° 12'04" West for 8.98 feet; thence North 52° 47'56" East for 32.87 feet; thence South 37° 12'04" East for 9.00 feet; thence North 52° 47'56" East for 37.80 feet; thence South 37° 12'04" East for 96.59 feet; thence North 52 ° 47'56" East for 7.22 feet; thence South 37° 12'04" East for 46.89 feet; thence South 52° 47'56" West for 98.78 feet to the POINT OF BEGINNING. Outpatient Center: A portion of Tract "A", Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of said Tract "A", thence South 54 ° 03'23" West along the Southeast line of said Tract "A" for 304.84 feet; thence North 37° 12'04" West for 529.73 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37° 12'04" West for 147.04 feet; thence North 52° 47'56" East for 30.01 feet; thence North 37° 12'04" West for 10.90 feet; thence North 52° 47'56" East for 33.18 feet; thence South 37° 12'04" East for 10.90 feet; thence North 52 ° 47'56" East for 29.92 feet; thence South 37° 12'04" East for 146.98 feet; thence South 52° 47'56" West for 9.99 feet; thence South 37° 12'04" East for 10.81 feet; thence South 52° 47'56" West for 31.11 feet; thence South 37° 12'04" East for 21.05 feet; thence South 52° 47'56" West for 11.04 feet; thence North 37° 12'04" West for 31.80 feet; thence South 52° 47'56" West for 40.97 feet to the POINT OF BEGINNING. Cooling Tower: A portion of Tract A, Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: 3 Book27672/Page1196 CFN#20110282259 Page 3 of 8 COMMENCE at the most Easterly corner of said Tract "A"; thence South 54° 03'23" West along the Southeast line of said Tract "A" for 203.34 feet; thence North 37° 12'04" West for 316.39 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37° 12'04" West for 20.00 feet; thence North 52° 47'56" East for 11.92 feet; thence South 37° 12'04" East for 20.00 feet; thence South 52° 47'56" West for 11.92 feet to the POINT OF BEGINNING. Storage Tank: A portion of Tract A, Mercy Hospital, according to the plat thereof as recorded in Plat Book 148, Page 51, of the Public Records of Miami -Dade County, Florida, being more particularly described as follows: COMMENCE at the most Easterly corner of said Tract "A"; thence South 54° 03'23" West along the Southeast line of said Tract "A" for 211.71 feet; thence North 37° 12'04" West for 561.06 feet to the Point of Beginning of the hereinafter described parcel of land; thence North 37° 12'04" West for 12.00 feet; thence North 52° 47'56" East for 4.60 feet; thence South 37° 12'04" East for 12.00 feet; thence South 52° 47'56" West for 4.60 feet to the POINT OF BEGINNING. TOGETHER WITH a non-exclusive easement over the following described land for ingress and egress and utilities, as defined in, and subject to, that Easement in favor of Mercy Hospital, Inc., a Florida corporation not for profit, executed by The Most Reverend Colemen F. Carroll, as Archbishop of the Archdiocese of Miami, dated October 8, 1970, recorded October 15, 1970, in Official Records Book 7003, Page 379: That portion of Tract 4, Vizcaya - James Deering Estate, according to the plat thereof as recorded in Plat Book 34, Page 46, of the Public Records of Miami -Dade County, Florida, described as follows: COMMENCE at the most Westerly corner of said Tract 4, Vizcaya - James Deering Estate, according to the plat thereof as recorded in Plat Book 34, Page 46, of the Public Records of Miami -Dade County, Florida, which point is 15 feet Northeasterly from the intersection of the prolongation Southwesterly of the Northwesterly boundary line of said Tract 4 with the prolongation Southeasterly of the center line of Halissee Street, thence run North 52° 47'45" East along the Northwesterly boundary line of said Tract 4, the same being the Southeasterly right-of-way line of South Miami Avenue for 1132.50 feet to the Point of Beginning of the parcel hereinafter described; thence continue North 52° 47'45" East along the Northwesterly boundary line of said Tract 4, the same being the Southeasterly right-of- way line of South Miami Avenue, for 40.00 feet to a point; thence run South 37° 12'15" East along a line parallel to the Southwesterly boundary line of said Tract 4 for a distance of 1020.00 feet to a point; thence run South 07° 47'45" West along a line for a distance of 56.57 feet to a point; thence run North 37° 12'15" West along a line parallel to the Southwesterly boundary line of said Tract 4 for a distance of 1060.00 feet to the POINT OF BEGINNING. 4 Book27672/Page1197 CFN#20110282259 Page 4 of 8 EXHIBIT "B" PERMITTED EXCEPTIONS 1. Rights of the United States Government with respect to control over navigable waters, or lands which formerly constituted navigable waters, for purposes of navigation and commerce. 2. Restrictions, dedications, and easements contained on the Plat of Mercy Hospital, recorded in Plat Book 148, Page 51. 3. Grant of Easement to The Most Reverend Coleman F. Carroll, as Archbishop of the Archdiocese of Miami, recorded July 11, 1969, in Official Records Book 6482, Page 219; as amended by Amendment to Easements and Disclaimer recorded October 15, 1970, in Official Records Book 7003, Page 397; and as partially terminated by Mutual Cancellation of Floating Easement recorded July 27, 1978, in Official Records Book 10106, Page 1630. 4. Grant of Easement to The Most Reverend Coleman F. Carroll, as Archbishop of the Archdiocese of Miami, recorded October 15, 1970, in Official Records Book 7003, Page 379. 5. Easement recorded October 15, 1970, in Official Records Book 7003, Page 386. 6. Easement to Florida Power & Light Company recorded October 15, 1970, in Official Records Book 7003, Page 409. 7. Grant of Easement to the City of Miami recorded November 29, 1971, in Official Records Book 7457, Page 969. 8. Easement to Edward A. McCarthy, as Archbishop of the Archdiocese of Miami recorded July 27, 1978, in Official Records Book 10106, Page 1633. 9. Easement to Florida Power & Light Company recorded June 6, 1985, in Official Records Book 12532, Page 920. 10. Grant of Easement to Metropolitan Dade County recorded December 13, 1985, in Official Records Book 12729, Page 1678, as partially released in Official Records Book 27612, Page 4315. 11. Terms, provisions, restrictive covenants, and conditions of that certain Lease Agreement by and between Mercy Hospital, Inc., and M.R.I. Associates of Miami, Ltd., a memorandum of which is recorded in Official Records Book 13083, Page 2938. 12.Traffic Signal Easement to the County of Miami -Dade recorded July 27, 1990, in Official Records Book 14641, Page 1887. 13.Terms, provisions, restrictive covenants, and conditions of that certain Option and Lease Agreement from Mercy Hospital, Inc., as Lessor, and BellSouth Mobility, Inc., as Tenant, a Memorandum of which was recorded September 30, 1991, in Official Records Book 15212, Page 655. 14.Terms, provisions, restrictive covenants, and conditions of that certain Lease between Mercy Hospital, Inc., a Florida not for profit corporation, Lessor, Hospital Affiliates Development Corporation, an Indiana corporation, Lessee, and Egremont Healthcare 5 Book27672/Page1198 CFN#20110282259 Page 5 of 8 Associates, an Indiana general partnership, Assignee (Lessee), a Memorandum of Lease Agreement was recorded September 23, 1993, in Official Records Book 16063, Page 4545, as amended by First Amendment to Ground Lease and Operating Agreement dated as of February 28, 2003, and assigned to Sefardik Associates, LLC by Assignment filed March 6, 2003, at Official Records Book 21079, Page 2568, which leasehold interest is encumbered by that Leasehold Mortgage and Security Agreement recorded in Official Records Book 21079, Page 2832, as affected by that Consent and Subordination Agreement recorded in Official Records Book 21079, Page 2860, and as assigned in Official Records Book 24927, Page 3613, and amended and restated in Official Records Book 24927, Page 3617, and modified in Official Records Book 25743, Page 1431, together with the following supporting loan documents: a) Assignment of Rents and Leases recorded in Official Records Book 21079, Page 2946, as amended and restated In Official Records Book 24927, page 3651. b) UCC Financing Statement recorded in Official Records Book 21079, Page 2942. c) UCC Financing Statement recorded in Official Records Book 24927, Page 3664, as continued in Official Records Book 27655, Page 2337. 15. Declaration of Easement by Mercy Hospital, Inc. recorded September 23, 1993, in Official Records Book 16063, Page 4551. 16. Declaration of Restrictive Covenants by Mercy Hospital, Inc. recorded October 21, 1993, in Official Records Book 16097, Page 4977, 17. Declaration of Restrictive Covenants by Mercy Hospital, Inc. recorded November 1, 1993, in Official Records Book 16109, Page 61. 18. Easement contained in Abandonment and Relocation of Easement recorded December 29, 1993, in Official Records Book 16192, Page 3710. 19. Order before the Metropolitan Dade County Environmental Quality Control Board No. 94- 19, recorded in Official Records Book 16313, Page 2690. 20. Phosphate, Minerals, Metals and Petroleum Reservations and rights in favor of the State of Florida, as set forth in the deed from the Trustees of the Internal Improvement Fund, recorded in Official Records Book 16714, Page 894. 21. Grant of Easement to Metropolitan Dade County recorded July 28, 1995, in Official Records Book 16866, Page 1607. 22. Deed of Easement in favor of Bellsouth Telecommunications, Inc. recorded in Official Records Book 16911, Page 475. 23. PCS Site Agreement between Mercy Hospital, Inc. and PCS Primeco, L.P., a Memorandum of which was recorded November 7, 1995, in Official Records Book 16983, Page 24. 24. PCS Site Agreement between Mercy Hospital, Inc. and Spring Spectrum, L.P., a Delaware limited partnership, a Memorandum of which was recorded January 29, 1997, in Official Records Book 17508, Page 4560. 6 Book27672/Page1199 CFN#20110282259 Page 6 of 8 25.Terms, provisions, restrictive covenants, and conditions of that certain Ground Lease Agreement from Mercy Hospital, Inc., a Florida corporation not for profit, to LHT Miami, LLC, a Delaware limited liability company, dated September 21, 2000, a Memorandum of which was recorded September 28, 2000 in Official Records Book 19302, Page 4077, as amended in Official Records Book 22998, Page 2799, and affected by the Recognition Agreement recorded in Official Records Book 23124, Page 4082, which lease is encumbered by that certain Leasehold Mortgage from LHT Miami, LLC, a Delaware limited liability company, to First Union National Bank, in the original principal amount of $8,849,000.00, dated September 26, 2000, filed September 28, 2000, in Official Records Book 19302, Page 4149, as affected by Cross -Default and Cross- Collateralization Agreement recorded in Official Records Book 19302, Page 4265; as amended by Modification Agreement recorded in Official Records Book 20316, Page 131; as assigned to General Electric Capital Corporation and General Electric Capital Assurance Company recorded in Official Records Book 21664, Page 580, as modified by Notice of Future Advance and Amended and Restated Mortgage recorded in Official Records Book 21664, Page 587, as affected by Recognition Agreement recorded in Official Records Book 22136, Page 2624, as modified by Amended and Restated Mortgage, Assignment of Leases and Rents, Security Agreement and Fixture Filing recorded in Official Records Book 22916, Page 3419, as assigned to California State Teachers' Retirement System by Assignment of Liens and Loan Documents recorded December 17, 2004, in Official Records Book 22916, Page 3458, and modified by Notice of Future Advance, Mortgage Modification and Amended and Restated Mortgage, Security Agreement and Fixture Filing recorded in Official Records Book 23124, Page 4021, and affected by that Recognition Agreement recorded in Official Records Book 23124, Page 4082, together with the following supporting loan documents: a) Assignment of Leases and Rents from LHT Miami, LLC to First Union National Bank recorded in Official Records Book 19302, Page 4246. b) UCC-1 Financing Statement securing First Union National Bank recorded in Official Records Book 19302, Page 4284, as assigned to California Teachers' Retirement System by Assignment recorded in Official Records Book 22916, Page 3464, and further assigned in Official Records Book 23154, Page 735, and modified in Official Records Book 23154, Page 827. c) Assignment of Leases and Rents to General Electric Capital Corporation recorded in Official Records Book 21664, Page 643. d) Assignment of Leases and Rents to General Electric Capital Corporation recorded in Official Records Book 23124, Page 4067. 26,Terms, provisions, restrictive covenants, easements and conditions of that certain Reciprocal Easement and Operating Agreement between Mercy Hospital, Inc., a Florida corporation not far profit, and LHT Miami, LLC, a Delaware limited liability company, recorded September 28, 2000, in Official Records Book 19302, Page 4084, as amended by First Amendment to Reciprocal Easement and Operating Agreement recorded in Official Records Book 19361, Page 4027. 27.Terms and conditions in that certain Sovereignty Submerged Lands Lease Renewal, bearing BOT No. 130377636, executed by the Board of Trustees of the Internal Improvement Trust Fund of the State of Florida and Mercy Hospital, Inc., a Florida nonprofit corporation, as recorded in Official Records Book 26273, Page 681, of the Public Records of Miami -Dade County, Florida. 28. Covenant recorded in Official Records Book 23889, Page 523. 7 Book27672/Pagel 200 CFN#20110282259 Page 7 of 8 CPR BK 27672 PG 1201 LAST PAGE 29. Agreement for Water and Sanitary Sewage Facilities between Miami -Dade County and Mercy Hospital, Inc. recorded in Official Records Book 23889, Page 666. 30. Easement in favor of Miami -Dade Water and Sewer Department recorded in Official Records Book 25836, Page 1600. 31. Easement in favor of Florida Power & Light Company recorded in Official Records Book 26191, Page 208. 32. Easement in favor of Miami -Dade Water and Sewer Department recorded in Official Records Book 26665, Page 1584. 33.The following matters as disclosed on survey Job No. 100602, prepared by Fortin, Leavy, Skiles, Inc., dated August 18, 2010: a) Asphalt pavement, concrete walks and curbs located over the following easements: FP&L Easements recorded in Official Records Book 7003, Page 409, and in Official Records Book 26191, Page 208; Utility Easement recorded in Official Records Book 7457, Page 969; Water and Sewer Easements recorded in Official Records Book 12729, Page 1678, in Official Records Book 16866, Page 1607, in Official Records Book 26665, Page 1584, and in Official Records Book 27582, Page 523. b) Emergency Department Expansion Building located over the Utility Easement recorded in Official Records Book 7457, Page 969. c) Fence encroaches beyond the property's southwesterly boundaries into a portion of Tract 4, Plat Book 34, Page 46. d) Water meters, water valves, gas meters, sanitary sewer manholes, valves, and cleanouts, and fire hydrants located throughout the property but not within any recorded easements. 34. Covenant Running with The Land in Lieu of Unity of Title and Release of Unity of Title recorded in Official Records Book 27466, Page 2473. 35. Easement in favor of Miami -Dade Water and Sewer Department recorded in Official Records Book 27582, Page 523. 36. Unrecorded Master Lease as evidenced by that UCC Statement, recorded in Official Records Book 27072, Page 2494. 37. Amendment to Agreement recorded in Official Records Boo 355267v8 8 k Page / t ii Book27672/Page1201 CFN#20110282259 Page 8 of 8 CITY OFMIAMI 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 agreement to support or withhold objection to the requested approval, relief or action. "Consideration" includes any gift, payment, contribution, donation, fee, commission, promise or grant of any money, property, service, credit or financial assistance of any kind or value, whether direct or implied, or any promise or agreement to provide any of the foregoing in the future. Individuals retained or employed by a principal as a lobbyist as defined in Sec. 2-653, and appearing before the City Commission or any of its boards, authorities, agencies, councils or committees solely in the capacity of a lobbyist and not as the applicant, or owners' legal representative are not required to fill out this form. NAME: Barbara Simmons (First Name) (Middle) (Last Name) HOME ADDRESS: A rose Lune CITY: (?)Gi (Address Line 2) STATE: Florida ZIP: 33,3%'7 HOME PHONE: CELL PHONE: 9,5q - et,2 _ FAX; 365 _a0.�-'� � it) EMAIL: bOtr ,Yly-rNot-1SC_ TC_R Vka (WI CDre_ •C-Orn BUSSINESS or APPLICANT or ENTITY NAME Plantation General Hospital Limited Partnership BUSINESS ADDRESS: 3663 S. Miami Avenue, Miami, Florida 33133 (Address Line 1) (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. Heliport for Hospital/Trauma Center 2. Ilas 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? fYES IIIN0 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. Doa. No.:86543 M IA7075822.1 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. b. c. * Additional names can be placed on a separate page attached to this form. 4. Please describe the nature of the consideration. 5. Describe what is being requested in exchange for the consideration. ACKNOWLEDGEMENT OF COMPLIANCE 1 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 2. no application from any person or entity for the same issue shall be reviewed or considered by the applicable board(s) until expiration of a period of one year after the nullification of the application or order. 2i--`7f PERSON SUBMITTING DISCLOSURE: nature Barbara Simmons Print Name Sworn to and subscribed before me this 1. 1 day of The, foregoing ._ instrument was acknowledged before me by 11Pt kertaa r: 5_s ___, who has produced as identification and/or cnsonal/y know to me and who did/did not take an oath. STATE OF FLORIDA CiTY OF M1A1v1I G,4 p "57------). MY COMMISSION Notary EXPIRES: Ft'S.a. ZO%4 Lore,tt~ 4M Print Name Enclosures) ����� �� s Doc. No.:865� Page 2 M IA7075822.1 orr� LORENA ROMERO Notary Public - State of Florida My Comm. Expires Feb 9, 2014 Commission # DD 960149