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William W. Riley - Betsy Ross Owner, LLC w c-) City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 ,-, - � y LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained,whether paid or not, by a principal who seeks to encourage the passages defeat or modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, re-commendationtV 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. Riley William W. NAME OF LOBBYIST: (Last) (First) (M-I) Gray Robinson,P.A. 1221 Brickell Avenue,Suite 1600 Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER:305-913-0541 FAX NUMBER:305-416-6887 EMAIL:William.RileyCo)Gray-Robinson.com Please notify this office if your contact information changes:address,phone, or e-mail address. 1. LOBBYIST RETAINED BY: Betsy Ross Owner,LLC,a Delaware limited liability company NAME OF PRINCIPAUCLIENT: Betsy Ross Owner,LLC 1841 Broadway Suite 800 New York New York 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (917)414-8200 (305)416-6887 jo,iathanplutzilc @gmail.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Ocean Court,LLC,a Florida limited liability company NAME OF PRINCIPAUCLIENT: Ocean Court,LLC 1841 Broadwa .Suite 800 New York New York 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (917)414-8200 (305)416-6887 jonathanplutzik @gmail.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: 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, t PARTNERSHIP OR TRUST: j ti.SPECIFIC.LOBBY ISSUE All land use,zoning,permitting and code compliance matters relating to properties located at 1440 Ocean Drive and 1433 Collins Avenue Issue to be lobbied(Describe in detail); iii.C.ITY 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 general nature of the subject contractual relationship. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO 1 title of person to be lobbied { All elected and appointed officials of the City of Miami Beach and City None i X employees i 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. Sec 2-482 Any Financial, Familial or Professional Relationship Not Applicable IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $400 per hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required) 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 lobbying 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 Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ❑Yes. ®No: Are you lobbying 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 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 ®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 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. gnature of Lobbyist 1 do solemnly swear that all of the foregoing facts are true correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Be h City Co an fl report ing quirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: ENTIFICATION: ❑ Produced ID ❑ Produced ID Form of Identification ___. Form of Identification Personally known(Lobbyist) ❑ Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida County f Miami-Dade tY ;�;.p�Y.,�•., ZAIDAAlfARO tate of Florida, County of Miami-Dade Sworn a nd subscribed befp e me wf ' .. _ MYOt)USSION N EE 19M81 worn and subscribed before me T i_s y of f 2013 EXPIRES:August 2s,2Uiii his day.of. Bonded 7hru Notary Ptlic Undemiters 2013 iI y ignature of Public No ary=State of Florida Signature of Public Notary—State of Florida otarization of Lobb "st's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid MCR# Date Paid Lobbyist Registration Form received and verified by: City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,WWW.miamibeachfl.00v CITY CLERK Office Rafael E.Granada,City Cleric Ci lerk miamibeachfi.gov Tel:305.673.7411 , Fax:305.673.7254 LOBBYIST NAME William W. Rilev I understand that no later than February 28 of each year]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. 1) 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, or I am no longer lobbying on that issue or for that principal, 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 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. V/ V. - 10/1,3 !,3 Signa re AV l6ate Miscellaneous Cash Receipt CITY OF MIAMI BEACH No 3 8 , ® Cash ®Credit Card heck# a ::J. /15 20.B Received of ti_�` .l •,�, _.,� Y • +�„ U:.�,� ...� r v."C:-(�r' '�."�''Gr.}.0..),31�+•J r L.3'.(`i f, �'• !fi y/ /Address I X- ' ; � � ,� _ r° Y�� f�_. ?;. / For 6 (THIS INFORMATION MAST BE COMPLETED) Office of FinanCer Director By Account Number: ; l 1��• /'W Pr®parer. i f` �i. f Dept. s + E)(T° ti.e ;' a M!