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Jose L. Gomez - Miami Beach Lincoln, LLC ® MIAMI BEACH City of Miami Beach Office of the City Cler �9 ►12� 1700 Convention Center Drive Miami Beach F1_dAg9 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 Ordinance 2004-3435. GOMEZ, JOSE L. NAME OF LOBBYIST: (Last) (First) (M.1) BEILINSON_GOMEZ ARCHITECTS P.A. 8101 BISCAYNE BLVD, SUITE 309, MIAMI, FL 33138-4664 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-559-1250 x.208 305-551-1740 JG@BEILINSONARCHITECTSPA.COM _ TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: MIAMI BEACH LINCOLN LLC NAME OF PRINCIPAUCLIENT: c/o MIAMI BEACH LINCOLN M LLC 801 ARTHUR GODFREY ROAD, SUITE 600, 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: �5-+epl O_V\ > �,QS f�Q/I�j`�� &P a m 4HOCTebRO, o�_ e-- LLC. n rFs � 0_04 0- n a �.�- �• IDENTIFY ER O DIRECTL.,Y9DIRECT Y A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Jr'4p—,ii.SPECIFIC LOBBY ISSUE: CERTIFICATE OF APPROPRIATENESS FROM THE HPB FOR AWNING DESIGN FOR 719 LINCOLN ROAD Issue to be lobbied(Describe in detail): III.CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4)Include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered Into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's commencement of service with the city to the present date,stating the eneral nature of the subject contractual relationship. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied HISTORIC PRESERVATION BOARD X Pursuant to City Code Section 2-482(8)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. Sec 2-482 Any Financial,Familial or Professional Relationship NONE F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc / i i IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $250/HOUR B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $250/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 &No: Are you lobbvina on a present or pending bid for Goods,eauipment or services,or on a present or pending award for goods,eauipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ® Yes 0( No: Are you lobbying on a pending application for a Development Agreement with the City or application for chance of zoning map designation or chance to the City's Future Land Use Map? 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. O Yes 8(No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSAT ON RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED FEVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. S nature Lobbyist Je,41r%E L. G MEZ I do solemnly swear that all of the foregoin is are tr and c rrect and th I have read or am familiar with the provisions contained in Section 2-482 of the Miami ch C1 ode a all reporting requirements. Signature of Lobbyist: Signature of Principal/Clien . )au VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: cc 46 Produced ID W ":�, 4E Produced ID a ,° N CM N Form of Identification o C Co Form of Identification N o ,CV d CU W Personally known(Lobbylst) ' '� Personally known(Principal) N ca x c VII. SIGNATURE AND STAMP OF NOTARY: B a uj a' E E z E o U State of Florida, County of Miami-Dade " State of Florida,County of Miami-Dade a 0 ;, Sworn to d subscrib d before me Sworn and subscribed before me This day of ,2013 ���`'"• •,, This day.of ,201S ,•;� bo;., AAl—La Ul AAA-,e!:�7 Signatur of Public Notary—Stat f Florida a,, , 5.;,• Signatur Public ota y—State of Florida ,,y , St,.• Notariza ion of Lobbyist's Signature °"°"'" Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF O L Annual Registration fee: [ ]Yes[ o Amount Paid$ 5Mt OCLMCR# Date Paid FACLER\$ALL\aFORMS\LOB ST FORMS\Lobbyist Registration.Form.doc Organization Chart for Miami Beach Lincoln, LLC 719 Lincoln Road 801 Lincoln Road 826 Lincoln Road Terranova Corporation,a r. + Florida Corporation Property Manager& 100% Leasing Agent Miami Beach Lincoln, LLC, Stephen H.Bittel a Florida limited liability company 95% 0%,managing member 5% Acadia Miami Beach Miami Beach Lincoln Manger,LLC,a Miami Beach Lincoln Investors,LLC a Lincoln Member,LLC,a Florida limited(lability company Florida limited liability company Delaware limited liability company 100% 1000/0 100% Acadia Strategic Stephen H.Bittel2-100•/6 Stephen H.Bittel and Family-25.86%economic/100%control Opportunity Fund 1V, Various Investors-74.14%economic LLC a Delaware limited liability company' ' Acadia Strategic Opportunity Fund is an affiliate of Acadia Realty Trust(NYSE:AKR) 2 Stephen H. Bittel may sell interests in Miami Beach Lincoln Manager to other investors, but at all times he shall maintain control. Lohhuict Rardatratinn Fnrm raraivarl anel wariflad hu- F: =crm.dac Revised 1/11/2011 City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www,miamibeachfl.gov CITY CLERK Office CityCIerk@miamibeachfI,gciv Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: JOSE L. GOMEZ I understand that no later than February 28th of each I must file the following form, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues. I) Lobbyist Expenditure and Compensation Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and for code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to timely file a Statement and in addition to any other penalties which may be imposed as provided in Section 2-485. 1 , a fine of $50.00 a day shall be assessed for all Statement(s) 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, 2012, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Mi i-Da e County Commission on Ethics and Public Trust. 8/27/2013 Sikature: JO E L. GOMEZ Date: FACLER\$ALL\aF0RMS\LOBBYIST FORMSTobbyist Registration Form.doc t S e , r a i 7 , _ rf ,Miscellaneous Cash Receipt CITV60F MIAMI BEACH 7 l = No. t Cash Credit Card C1 Check# ` .,, Address f � �! c-��.ry�r_i Ep tp�,�• v - .�F, rf � �- -i .� ��� - ,t •p�, .'.rs.:.�'-'_n"�' �"', r .L r'"t�. -��. �.� � Y�.`j,� S - F©� '.2. T� F -.Y D x (TOIS INFORMATION MUSTSE COMPLETED) Offic®®f finance®tr®ctor.> 4` 1 st, Jr-ti 4 Y "� ount Number." ( 33 ) k1 P l- qr -'.'4 7�.L ! F fJ �,': P 7 '- 1 _ ; .K__ [( _ J'IYFt `�`f . i ({�f! L �Pra 8re�• 4." y7ti{. T° F. _ t t .F y De®g.� e. -iy_ �°'t:,..._j' E' f. !r` f r r F �.Yu .a -M - t r.5 r ,l• -t .P t. x .�1 L