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City of Miami Beach Office of the City Clerk r r.,-. °•- r. 7 - ,• �..
1700 Convention Center Drive, Miami Beach, FL 33139`- t' - • _
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.
Moehring Robert
NAME OF LOBBYIST: (Last) (First) (M.i)
DOMO Studio LLC, 420 Lincoln Road, Suite 506 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-674-8031 robert@domodesignstudio.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:
5446 NBR, LLC
NA OF PRINCIPAL/CLIENT:
�Ed Box 40249 Miami Beach Florida 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-542-1131 tmgeng64 @aol.com
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
IFill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
i • NAME OF CHIEF OFFICER;PARTNER,OR BENEFICIARY see attached
• IDENTIFY ALL PERSONS HOLDING.DIRECTLY QR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: see attache
O , Development Approvals and Permitting Issues, including,but not limited to Historic
�l' ''rese star a ISSUE.,:
moard,Planning Board, Design Review Board, Board of Adjustment, Land Use Development
Committee,and City Commission, if necessary, relating to the property located at 5446 North Bay Road, Miami Beach FL.
Issue to be lobbied(Describe in detail):
in CITY_AP AGENCIES/INDIVIDUALS 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 eneral 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 , Building, Publlic Works and Fire Dept Staff None x
--- B,DRB,HPB,BOA,City Commission;and-Land-Use None
X
Develop.ment,Cnmittee,as necessary
Pursuantto 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 2-4820 Any Financial,Familial or Professional Relationship -1
F:ICLER\$ALL.1aFORMS\LOBBYIST FORMS\L.obbyist Registration Form.doc
("\I"
Iv. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
I --(54,4,
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 2S6 l, A/
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 XiNo: 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 Beath 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.
_YesXNo: 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 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.
v•-aimoot_.
S' naturetfLobb is
I �9 Lobby
is
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 Miam Pach Ci Code and all reporting requirements.
Signature of Lobbyist: h
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA•N: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
—
Form of Identification Form of Identification
Personally known(Lobbyist) ?<Personally known(Principal)
VII. SIGNATURE AND STAMP OF NO ARY-
opst.,�_ MICHELLE BRADY State of Florida,County MICHELLE BRADY
State of Florida,County of Miami-Dade A 1^ MY COMMISSION fiff901896 ty of Miami'oars*B,
Sworn to and subscribed before me Sworn nd subscribed bef.re - MY COMMISSION#Ff901896
EXPIRES:AUG 09,2019
This Al, day of i t, k i .201 e' Bonded through 1st State Insurance This day of k 's, ri:. EXPIRES:AUG 08,2019
�/ ki dit I Bonded through 1st State Insurance
Signature of Public Notary—Stat::f Florida Signature of Public Notary—Slat g of Florida
Notarization of Lobbyist's sig ure Notarization of Principal's signature
TO BE COMPLETED BYCITY CLERICS STAF ON
Annual Registration fee: r Yes f;: ]No: Amount Paid$ CR# ages a® Date Paid
Lobbyist Registration F ceived and verified by
. 4 ... . Revised
F:\CLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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A Aki A sh: A-1 t 1 :; A.
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: Robert Moehring
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.
---74d-4 ::: :: ///eutC-
Signature: Date:
C:1Users\clerhatl\AppData\Local\Microsoftlwindows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
OWNER AFFIDAVIT FOR INDIVIDUAL OWNER -
STATE OF
COUNTY OF
I, ,being first duly sworn,depose and say that I am the owner of the property described and which is the subject
matter of the proposed hearing;that all the answers to the questions in this application and all sketches data and other supplementary matter attached to
and made a part of the application are true and correct to the best of my knowledge and belief. I understand this application must be completed and
accurate before a hearing can be advertised. I also hereby authorize the City of Miami Beach to enter my property for the sole purpose of posting a
NOTICE OF PUBLIC HEARING on my property as required by law and I take the responsibility of removing this notice after the date of hearing.
PRINT NAME SIGNATURE
Sworn to and subscribed before me this day of , 20_ The foregoing instrument was acknowledged before me by
,who has produced as identification and/or is personally known to me and who did/did not take an
oath.
NOTARY PUBLIC
NOTARY SEAL OR STAMP
PRINT NAME
My Commission Expires:
ALTERNATE OWNER AFFIDAVIT FOR
CORPORATION or PARTNERSHIP
tog
(Circle one)
STATE OF
COUNTY OF .J Al A i DI O
�•I, 1 being duly sworn,depose and say that I am the • illan of JV
and as such,have been authorized by such entity to file this application that all answers to the questions in the
application and all sketches,data and other supplementary matter attached to and made a part of the application are true and correct to the best of our
knowledge and belief,that the corporation is the owner/tenant of the property described herein and is the subject matter of the proposed hearing.We
understand this application must be completed and accurate before a hearing can be advertised. I also hereby authorize the City of Miami Beach to enter
the subject property for the sole purpose of posting a NOTICE OF PUBLIC HEARING on the property as required by law and I take the responsibility of
removing this notice after the date of hearing. J
TfO 61w
PRINT NAME '- SIGNATURE
Sworn to and subscribed before me this N day of J� , 20 .The foregoing instrument w- acknowledged before me by
of , on behalf of such entity, who has produced
as identification and/or is personally kno o me and who did/did not take an oath.
NOTARY SEAL OR
��, „,,,, DAVID SOLOMON
� ���PAY pV��� _
4 r°, �`�� Notary Public-State of Florida ".
3 NOTARY PUBLIC
_• , s•:ray Comm.Expires Aug 10,2010
"fin F/ p v .� (,
Commission r FF 113494 J]
''' Bonded Through National Notary Assn.` P NAME
My Commission Expires:u� � - `� "' ' `"' y
4
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CITY OF MIAMI BEACH
DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
P
1. CORPORATION
If the property which is the subject of the application is owned or leased by a CORPORATION,list ALL of the stockholders,and
the percentage of stock owned by each. Where the stockholders consist of another corporation(s),trustee(s),partnership(s)or
other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having
the ultimate ownership interest in the entity.*
ST16 AGR-,
CORPORATION NAME
NAME AND ADDRESS %OF S OCK
D 16 vock Lio 0
A E t n
a ge 9/0
1p
r AIIIMAIFIEILYMNIENITIFIgi 3-109
CORPORATION NAME
NAME AND ADDRESS %OF STOCK
IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL
STOCKHOLDER'S NAME,ADDRESS, OFFICE AND PERCENTAGE OF STOCK ON A SEPARATE PAGE.
NOTE: Notarized signature required on page 8
6
!Miscellaneous Cash Receipt j , , � # t 19; f Iir 1)1 6
rt=.T F MIAMI BEACH vtr:P-t , y ( ,.3-1_,. . ,..1.89: $.1•..,,200,;.(7,1-9_:
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5:-� �Y . 0 Cash 0 Credit Card Check# $1'
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Received of
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Address �.
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_ (THIS INFORMATION
MUST BE COMPLETED) Offic of Finance Director r
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Account Number: U✓ f 1/ / Jp - !-�1 yy('
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City City of Miami Beach-Florida
Finance Department
1 City Hall
1530613-1 11/02/2015 BR1 T113
Mon Nov02,2015 04:32PM Trans#15-15
15 $1200,00 MCRCLERK - MCR-City Cler
* MCR#: 408080
1 ITEM(S): TOTAL: $1200.00
Check (1401) PAID $1200.00
Have a nice day!