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Rai Fernandez - M-4000 Alton Owner, LLC Lice fo b MIAMI B moues,��- City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 331392015 Auf+, 26 P;; fi: 29 LOBBYIST REGISTRATION FORM L1 i, r,' " ' Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage-the passage,I 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. Fernandez Rai NAME OF LOBBYIST: (Last) (First) (M.l) Bermello Ajamil & Partners, Architects, Inc. 118 East 28 Street, Suite 501 New York, NY 10016 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (212) 334-2050 (212) 334-0453 rfernandez abermelloaiamil,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: Camilo Miauel Jr. NAME OF PRINCIPAUCLIENT: M-4000 Alton Owner, LLC 119 Washington Avenue, Suite 505 Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 531-2426 (305) 675-8447 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: Camilo Miguel Jr. • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNFRSHIP OR TRUST.See attachment ll.SPECIFIC LOBBY ISSUE: Development Board Approvals for 4000 Alton Road. Miami Beach, FL 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 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 Formrevised 5-30-2012.doc • IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$ 1 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 X No: Are you lobbvina on a present or pending bid for aoods.eauipment or services.or on a present or pending award for aoods.eauipment 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 lobbvina on a pending application for a Development Aareement with the City or application for change of zonina 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 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 BEACI-( MS THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist 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: Signature of Principal/Client: I' :i.er,' I 0 •igue, r., '°-si°en o vi---4 111 Alton MUM,LLU,Manager of M-4000 Alton Owner,LLC _-___.._-..-_VI. ..............LOBBYIST..IDENTIFICATION:.._.---..-.-...._._...._.---....__..._.._..._....._...___._-.--_-.---....._._..__.._._._.-.-PRINCIPAL.IDENTIFICATION:__---.__.._____.-._-.-----_._____.-..---..___...._.-.-__ Produced ID Produced ID Form of Identification Form of Identification 1 g o 1 N i °�NO~ A Personally known(Lobbyist) X Personally known(Principal) tj 3 VII. SIGNATURE AND STAMP OF NOTARY: Ito w State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade 1 di if Sworn to and subscribed before me Sworn and subscribed before me This day of ,2015 This 26th day of August ,2015 �" U (_ fA,t/ 4 , •Signature of Public Notary—State of Florida Signature of Public Not — tate of Florida 4 tom '': Notarization of)...obbvist's signature Notarization of principal's,signature `'',r1,#/e 4' - 8_ TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ,- • .0 Annual Registration fee: [ Yes[ ]No Amount Paid MCR# z10 7 r Date Paid K/? l/ .n"1° Lobbyist Registration Form ceived and verified by: C:\Users\clerhatI\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH 1Lobbyist Registration Formrevised 5-30-2012.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$ 4 la '* B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): 4-7/C0 i F(‘1 (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 X No: Are you lobbvina on a present or Dendina bid for aoods.eauioment 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 lobbvina on a oendina application for a Development Aareement with the City or application for chanae of zoning map desianation or chanae 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 reimbursements V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR. EACH LOBBYIST SH L-I S 1 MITTO THE CITY CLERK A SIGNED STATEMENT UNDER OATH. LISTING LOBBYING EXPENDITURES. AS WEL AS COMPENSATION RECEIVED. IN THE CITY OF MIAMI BEACFI EQZ THE PRECEDING CALENDAR YEAR. A ST• EME 4 T SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REP'4 ERIOD, :w � Si•,eir/f/iwy yis t I do solemnly swear that all of the fa re.•ing facts true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Bea 40 ode and a reporting requirements. `i,-� . Signature of Lobbyist: `���:, /'���t4/ Signature of Principal/Client: 9 P 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,County of Miami-Dade State of Florida,County of Miami-Dade Sworn to and subscribed before me Sworn and subscribed before me This c 77+ day of R116 0-67-,2015 This day of ,2015 ILLY i'LOURDES E.THUROW mg-, MY COMMISSION#FF037633 nature of Public Notary-State of Florid.. ' EXPIRES:August 18,208rig ture of Public Notary-State of Florida Notarization of Lobbyist's signature �`�- rization 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 C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc • IF:\CLE istration Form.doc Revised 04/27/2012 I MIA BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, 4 www.miamibeachil.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel:305.673.7411 , Fax:305.673.7254 LOBBYIST NAME: Rai Fernandez 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 automatic JI suspended from lobbying until all fines are paid, unless the fine has been . appeal to the Miami-Dade County Commission on Ethics and Public Trust. A'. -AUEI 2(a, /201 SignalwAr: • Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc SUPPLEMENTARY DISCLOSURE OF INTEREST Beneficial Ownership Interests in M-4000 Alton_Owner LLC Alicia L. Jarrett 73% 100 S Pointe Dr.#3804 Miami Beach, FL 33139 Camilo Miguel, Jr. 24% 119 Washington Avenue, Ste. 505 Miami Beach, FL 33139 • f • Miscellaneous Cash Receipt , . . . , G L:01 0.,!; f=1 2-,15.-i 001 121 CITY OF MIAMI BEACH • :,, _:, 1:,,,, 152;. . t } i $ ,cif:..xt,o � T- • No $ L `• 'L t„ T - ❑ Cash ❑Credit Card •Check# 0 `)0 2b`"( -I "�~ $ 2.,6 0, • A � 2t 20 1.c Received of 'Gt I CAk z } �. iIc5 .. 1c ` )41 ] {,fc _ it ' ihi,t*I- Address 4 For ;Y,4. - ,,K t�,ca j , i 2. 1ZL.?vl�f,/U (?CA, cs • ! (' 55 • • (THIS INFORMATION MUST BE COMPLETED) Office of Finance Director By C .so sn� - Account Number: G 3 4— 9600 . .61 '14`I IN) 1\ 'Pre arer• Dept: I ,..-f-y I a "N. 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