Giovana Henao - Ahavas Torah Congregation Inc. •
L-12 (-- Lir Li
t\v/\I,At\/\J BEACH
27 PM
City of Miami Beach Office of the City Clerk 02 15 OCT I:
1700 Convention Center Drive, Miami Beach, FL 33139 13
LOBBYIST REGISTRATION FORM ` ' r 1✓
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.
G-1 DAr4f•
Henao
NAME OF LOBBYIST: (Last) (First) (M.I)
KZ Architecture 7580 NE 4th Court, Suite 116, Miami, FL 33138
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-865-9911 1305) 865-0572 Jaua(a.Iczarchitecture.corn
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Ahavas Torah Congregation Inc.
NAME OF PRINCIPAUCLIENT:
424 W. 40th Street Miami Beach FL 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 528-2275 Akivashawelagmail.com
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: Jamie Tarich,Shimon Segelman and Rabbi Hersh Neuhaus,Directors
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:NON-PROFIT
II.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues, including, but not limited to the Historic Preservation Board, Design Review
Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops
or Committees, if necessaru, relating to the propertu located at 424 W. 40th Street, Miami Beach. Florida.
Issue to be lobbied(Describe in detail):
lll. 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, City Commission,•Development None. X••Boards, Land Use Development Committee None. X•
and Commission as necessary 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
Norte.
None.
None.
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc .
ve;
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBY! COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 20
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $ I ZO kr"
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 XNo: Are you lobbvina on a present or pending bid for goods.eauioment or services.or on a present or pending
award for goods.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)(No: Are you lobbvina on a pendina application for a Development Aareement with the City or application for
chanae of zonina map desianation or chance 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 representina 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-(
FQE THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL B FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPO TING PERI•x /
r /f it,fi
Signs 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 Bk City Cede -. •`I reporting requirements.
Signature of Lobbyist: ' t
1T ' e Signature of Principal/Client: 1 Pvej
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND STAOppan T4R `
a 0,104, CYNTHIA ROMAN
‘` '`; State of Florida, County of Miami-Dade
State of Florida, County of Miam �' Notary Public=State of Florida
Sworn nd subscribed be ore I. Commission I FF 204105 Sworn and subscribed before me
This .day of n! My Comm.Expires Feb 26.2019 This day of 2015
(i 8orrdedtlMOUpf1National Not Assn
Signature of ublic Notary—State of Florida Signature of Public Notary—State of Florida
Notarization of Lobbyist's signature . Notarization of principal's,signature
TO BE COMPLET ' BY CITY CLERK'S STAFF ONLY
._ .. .•. I 'ar
Lobbyist Registration Fo received and verified by .
i
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIS COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 120 Ar-
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $ 1 20 11 r
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 XNo: Are you lobbvina on a present or oendina 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 XNo: Are you lobbvina on a pendina application for a Development Aareement with the City or application for,
chanae of zonina map desianation or chanae 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 XNo: 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 BEACH
FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO,
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD.
c -Dr"e' 4Vii" p'j G 1�G V'2 Q t�j
Signature of Lobbyist r
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: �—�
VI. LOBBYIST IDE • -I N• PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) X Personally known(Principal)
�� ANNA E.ALAME'U,•. o,�PaY Pae�� ,.....
VII. SIGNATURE AND STAMP OF NOTARY: = MY COMMISSION#FF 0 �,_� I�: ,,,,,,v n rr 0b3�+•io
EXPIRES:September 12,2k.;..,.., '_. * EXPIRES:September 12,2017
State of Florida, County of Miami-Dade S e einfed t 6f.,f�l.'. ,'`DaeledThn.sud?et Notary SeNirr.c
Sworn to and subscribed before me -Sworn and subscribe before me
This day of ,2015 This 2--t day of _ ,2015
1
Signature of Public Notary—State of Florida ign. . - : M17 Notary—State of Florida
Notarization of Lobbyist's signature otariza ••• - rincipal's,signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amou.nt.P_aid_S MCR# Date Paid
Lobbyist Registration Form received and verified by:
•
/ AM' BE AC H
City of Nliami Beach, 1700 Convention Center Drive. Miami Beach, Florida 33139, www.miamibeachll.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk@miamibeachll.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Giovana Henao
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.
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Signs re: ' ate: .
C:\Users\clerhatlWppData\Local\Microsoft\Windows\Temporary Internet Files\ContentOutlook\83LGQDDH\Lobbyist Registration
Form revised 5-30-2012.doc
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