Jeffrey S. Bass - South Beach Tristar, LLC CAL"(
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City of Miami Beach Office of the City Clerk �'� �.4- 0
1700 Convention Center Drive, Miami Beach, FL 33139 17° ,,G'`1
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.
Bass Jeffrey S
NAME OF LOBBYIST: (Last) (First) (M.I)
Shubin & Bass, P.A. 46 S.W. 1st Street, Third Floor,Miami, FL 33130
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 381-6060 (305) 381-9457 jbass @shubinbass.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address'i2
I. LOBBYIST RETAINED BY:
South Beach Tristar,LLC(c/o David Edelstein,Manager) f -
NAME OF PRINCIPAL/CLIENT: . cp
South Beach Tristar 590 Madison Avenue,21st Foor,New York,NY 10022
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)':
(305)381-6060 (305)381-9457 jbass(a,shubiinba$_com
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL:(Optional)
F Cr, v
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] r-=
• NAME OF CHIEF OFFICER, PARTNER,OR BENEFICIARY: David Edelstein,Manager
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:David Edelstein,Jacqueline Mansfield,and Robert Futterman
II.SPECIFIC LOBBY ISSUE:
Approval of Settlement Agreement between South Beach Tristar,LLC,Miami Beach Community Church,and the City of Miami Beach
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 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
Miami Beach City Commission N/A 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
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) ,
$635/hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). $635/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 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 Section 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 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✓No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST S = BMIT TO THE CITY CLE-,. A SIGNED STATEMENT UNDER
OATH. LISTING LOBBYING EXPENDITURES,AS WELL S COMP SATION RECEIVE 14, 1 THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT .HALL BE Fl ED EVEN IF TH: HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
//
-'gnature of L.•. '-
I do solemnly swear that all oft or:L•oing facts ar- . •e an• correct and t have read or am familiar with the provisions contained
in Section 2-482 of the Miam. =each 'ity Code - l reporting requirements.
Y
Signature of Lobbyist: ce
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Signature of Principal/Client: W o 73 z
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ,'mob'O GO U ._
N a so
Oa NJ N U' m
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Produced ID • RUTH QUINTAVALLI Produced ID z x
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Form f Vo
�lotacy Public-State of Florida Form of Identification
' " ' • My Comm.'Expires Mar 9,201f Qc 22 02 0 a °
• �� , Commi sion'#EE 851527 = z ,�
✓ Personally known(Lob }.� w., Personally known(Principal) a
'∎' Bonded Through National Notary Assn. E
VII. SIGNATURE AND STA 0 NOTARY: ® a
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State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade
-.•• :1= ubscrib-• - me Sworn n subscribed befo a me
This " d • ���,its -. %, 2015 ay of 201 V 1 III
immir ,..,--d _ . _Signature of Public Cary—Slate of Florida Signature of Public Lary—State of Florida ih/Alt
Notarization of Lobbyist's signature Notarization of Pri cipal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: Yes[ ]No Amount Paid$ )o eV MCR# ' 1 I- Date Paid -3 19 /q
Lobbyist Registration Form received and verified by: • - . _ •. Aj_
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Rte'?a-'' n Fc m .o v Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
' M i AM BEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Jeffrey S. Bass
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 theme;,,'uired Statement by April 30th, 2012, shall be
•
automa '- . ly suspended from l• • -ing until all fines are paid, unless the fine has been
appe.. ed to he Miami-Dade . my Commission on Ethics and Public Trust.
March 9. 2015
Si• 4atur Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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mimAi BEAcH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
City Clerk's Office
Tel: 305-673-7411
Fax: 305-673-7254 Office Use Only
ANNUAL LOBBYIST REGISTRATION FORM
Name: Jeffrey S. Bass
Business Name: Shubin & Bass, P.A. ;
_i
Address: 46 SW 1st Street, Third Floor, Miami, Florida 33130
V_ ._-
Office Telephone Number: (305) 381-6060 -;
f. Ti
(305) 987-4008 "' T
Cellular Telephone Number: . r _
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Email Address: ,bass @shubinbass.com f-z
If more than one lobbyist, please list:
1) Jeffrey S. Bass, Esq.
2)
3)
4)
5)
6)
7)
Submit this form to the Office of the City Clerk, along with a check for $500 for each
lobbyist. Please make the check(s) payable to the City of Miami Beach.
For City Clerk's Office Use Only
MCR#: elo-7 4-t(
Amount paid: Date paid: 040/1 �/
/ /0)/5—
Processed by: . S - I-- ( Date: J
F:\CLER\$ALL\aFORMS\LOBBYIST F RMS\ANNUAL LOBBYIST REGISTRATION FORM reg.docx