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Russell W. Galbut - SOuth Beach Heights I, LLC /Ir.) miAmi , @Uo° City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 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. Galbut Russell W NAME OF LOBBYIST: (Last) (First) (M.I) Crescent Heights 2200 Biscayne Blvd. Miami FL 33137 • BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5700 (305) 573-8489 rgalbut a( crescentheights.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: Russell W Galbut NAME OF PRINCIPAL/CLIENT: • South Beach Heights I, LLC, 500 Alton Road Ventures, LLC, and 1220 Sixth, LLC 2200 Biscayne Blvd Miami Florida 33137 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5700 raalbut(a crescentheiphts.corn 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: • IDENTIFY ALL PERSONS HOLDING, DIRECTL OR INDIRECTLY,A 5%OR MOR OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: Development Board Approvals for 600 Alton Road, Miami Beach, FL Issue to be lobbied(Describe in detail): Ill. 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 general 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 Planning Staff, PB, HPB, BOA, DRB, Commission None X 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(g)Any Financial, Familial or Professional Relationship NONE C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration F rmr vi 5-30-2012.doc o e sed 5 30 2012.doc i • IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): r° (REQUIRED). V 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 X No: Are you lobbying on a present or pending bid for goods.eauipment or services. or on a present or pending award for aoods.•eauioment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes X No: Are you lobbying on a pending application for a Development Agreement with the City or application for chanae of zoning map designation or chance to the City's Future Land Use Mao? 3) Pursuant to Miami Beach City Code Section 2-482 (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 X No: Are you reoresentina a not-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 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 BEACU EQ$ THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD / . Signature of L byist f • I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: ' s Signature of Principal/Client: 7 �� VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: 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, Count of State of Florida,C. n o M, Ad-D „ , ,.. �,.. • Swor • .41-. subscribe• b r� a''e(,� DAYAMI AGUIAR `� =worn . sues.; :-,• ,e,$) e me DAYAMI AGUIAR ' 2015 This �.E, day of ,.fi'.-�-, '- •,�� Notary Public-State of Florida 0 is ..� d; 07 �Wig:ft%ate.-°- 'Notary Public-State of Florida ." iti , n- ;,�:My Comm.Expires Mar 16,2015 /� i 1011 4 I G 'J'` Commission # EE 70292 r 11,1,, •��`!,o _ d; My Comm.Expires Mar 16,2015 - - mission # EE 70292 Signature . L c Nota, f _._W_ .. ;. Signat re of .lic No :.TI— aa,�fFlorid- ' Notarizat on Lobbyist's signature Notari•atio,`of " -!z---,-'0,-- „,:._.;.._•- TO BE COMPLETED BY CITY CLERK'S STA F ONLY Annual Registration fee: [ ]Yes[ No Amount Paid$ �°”' MCR# 0 �4o Date Paid 2 A,ii Lobbyist Registration Form received and verified by: �,�.,,., C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc • F:\CLE istration Form.doc Revised 04/27/2012 1 A/\/\ : H City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk a miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Russell W Galbut 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, 2012, 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. /)d-SPK Signature: ate: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc 006 ailltV1 SUPPLEMENTARY DISCLOSURE OF INTEREST Interests in South Beach Heights I, LLC Percentage of Interest KGM Equities, LLC 100% 2200 Biscayne Blvd. Miami FL 33137 Interests in 500 Alton Road Ventures, LLC Percentage of Interest KGM Equities, LLC 100% 2200 Biscayne Blvd. Miami FL 33137 Interests in 1220 Sixth, LLC Percentage of Interest KGM Equities, LLC 100% 2200 Biscayne Blvd. Miami FL 33137 Interests in KGM Equities, LLC Percentage of Interest Sonny Kahn 2004 Irrevocable Trust 37% 2200 Biscayne Blvd. Miami FL 33137 Russell W. Galbut 2004 Irrevocable Trust 37% 2200 Biscayne Blvd. Miami FL 33137 Bruce A. Menin 2004 Irrevocable Trust 26% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Sonny Kahn 2004 Irrevocable Trust Percentage of Interest Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Russell W. Galbut 2004 Irrevocable Trust Percentage of Interest Child of Russell Galbut 50% 2200 Biscayne Blvd. Miami FL 33137 Child of Russell Galbut 50% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Bruce A. Menin 2004 Irrevocable Trust Percentage of Interest Child of Bruce Menin 33.33% 2200 Biscayne Blvd. Miami FL 33137 Child of Bruce Menin 33.33% 2200 Biscayne Blvd. Miami FL 33137 Child of Bruce Menin 33.33% 2200 Biscayne Blvd. Miami FL 33137 ti :;; k .1.14 ''c..l MUCTOCASSIMUMISZEMEr City of Miami Beach-Florida Finance Department 1 City Hall 1503413-1 02/03/2015 BR1 1118 Tue Feb03,2015 01 :35PM Trans#29-29 29 $350.00 MCRCLERK - MCR-City Clerk * MCR#: 401456 1 ITEM(S): TOTAL: $350.00 Check (00536) PAID $350.00 Have a nice day Y S tr f, \ � +r e..,� ..,-.t- ):f- 4 T 1 :i 1 _�_' • - '-''- llan . '' -Cash Receipt _ - CITY OF MIAMI BEACH 8 a, ••� -is - - rr No -- . - ,. ' '0 Cash [:Credit•Card Check;# 00 •. r $ :� -=t, • 20 ,3 - -`Received of - .l v .dam- -_- r� t . �r .1'C , - , 'vim !'` . : % -61=.;1 '.Address 0 - , - = 6ii • ,For j _ r V - - ri . „ ::":-.::,',:i.:.':::::::.:-.:::..l':':!:::-::.',1:••■,,-..''.' ''(THIS INtFORMATION MUST BE COMPLETE®) Office of:Finance Director t s _ t 'rte y� l, Account Number: . ., _ 4...(.,,, . Prepa`rer: LJ r L %6. --- Dept. t-- 1 °:� � /l. X35 -i:. f.. + <.-.,, ;Y