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Jose Gomez - S.F. Land, LLC 656S (o11, n <>4 / i\AIAM1 B EAC H City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 DC -2 9: 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. Gomez Jose NAME OF LOBBYIST: (Last) (First) (M.I) Beilinson Gomez Architects P.A., 8101 Biscayne Boulevard, Suite 309, Miami, FL 33138-4664 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 559-1250 (305)551-1740 iaabeilinsonarchitectsva.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: S.F. Land, LLC NAME OF PRINCIPAL/CLIENT: 6565 Collins Avenue, Miami Beach FL 33141 (BUSINESS NAME ANU AUUKLSS (Number and street) (city) (state) (Lip Gode) (305)866-8855 irasussman(a he-beach.net 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:See Attached. • • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: 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 necessary, relating to the property located at 6565 Collins Avenue,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 Staff for the Planning Department, Building Department, None. X Public Works and City administration, PB, HPB, BOA, None. X City Commission, and Mayor 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 None .IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Require $ 2 l .t-*OVV/ B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). tzs-e014Vu 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 Iobbvina on a present or oendina bid for aoods.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 X No: Are you Iobbvina on a pendina application for a Development Aareement with the City or application fo chanae of zonina 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 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 BEACH EQB 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: 5 F 1-ftr0 LL ._ ► � 11 '"' 5 +` ..•off. VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: �`_I- {'I. i -'fir°� Produced ID Produced ID 4 "e.,,,,"'�� Form of Identification Form of Identification o cad Personally known(Lobbyist) ,Personally known(Principal) y. 3 'CI CO • VII. SIGNATURE AND STAMP OF NOTARY: t { y T State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade �c+ c d g Sworn to and subscribed before me Sworn and subscribed before me m ;, This _day of , 2015 k Ii, k day of 2015 o N magi Nom ° t CO Signature of Public Notary-State of Florida S.n n. ,r!' ubli Notary- tate of Florida Notarization of Lobbyist's signature Nota . . of Principal 's,signature • TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[° No Amount Paid$ 3Cj MCR# LI 9;9-i Li Date'Paid ) ZI Z/1S— Lobbyist Registration Form received ndverified by IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Require $250/Hr. B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $250/Hr. 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 oendina bid for aoods._eauipment or services.or on a Present or pending award for goods.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 aDevelopment Aareement with the City or application fgC change of zonina 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 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-1 mg 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 r t re t ue and ••rrect and that I ave lea. or am familiar with the provisions contained in Section 2-482 of the Miami Be- - ••- =.• - I porting equirements. Signature of Lobbyist: Signature of Principal/Cli; t: VI. LOBBYIST IDE IFICATION: ■ PRINCIPAL IDENTIFICATION: O N fin Produced ID > o Produced ID Form of Identification o I Form of Identification X_Personally known(Lobbyist) e a 8 Personally known(Principal) 2 541 VII. SIGNATURE AND STAMP OF NOTARY :g, Fg State of Florida, County of Miami-Dade 'c� State of Florida, County of Miami-Dade Sworn to and subscribed before me °,.,,moo. . Sworn and subscribed before me This 1 day of tOVEM , 2015 �°° -� This day of ,2015 1114Astit-96V IL- U Signatur%of Public Notary–State Florida "u�,,,, Signature of Public Notary–State of Florida Notarization of Lobbyist's signat re T T—— Notarization of Principal's,signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY )Z l Annual Registration fee: [ ]Yes[ ]No Amount Paid$ 2)60 MCR# `'I 6A2,4� L-//Date Paid J Lobbyist Registration Form received and verified by: I F:\CLE istration Form.doc Revised 04/27/2012 MIAMI 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: Jose Gomez 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. II 11 \"2-0I s Signature: Date: CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST, 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.* S.F. Land, LLC. CORPORATION NAME NAME AND ADDRESS %OF STOCK S.F. Land Trust f/b/o Joel Sussman Family 40% 6565 Collins Avenue Miami Beach, FL 33141 S.F. Land Trust fjb/o Ira Sussman Family S0% 6565 Collins Avenue Miami Beach, FL 33141 S.F. Land Trust f/b/o Perri Stern Family 10% 6565 Collins Avenue Miami Beach, FL 33141 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 • CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 2.TRUSTEE If the property which is the subject of the application is owned or leased by a TRUSTEE,list the beneficiaries of the trust and the percentage of interest held by each. Where the beneficiary/beneficiaries consist of corporations(s), another trust(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.* S.F. Land Trust f/b/o Joel Sussman Familri TRUST NAME NAME AND ADDRESS %OF STOCK Matthew Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Elizabeth Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Benjamin Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Stephanie Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 S.F. Land Trust f/b/o Ira Sussman Familu TRUST NAME NAME AND ADDRESS %OF STOCK Mollie Sussman Davis 10% 6565 Collins Avenue, Miami Beach, FL 33141 Paige Sussman Danowit 10% 6565 Collins Avenue, Miami Beach, FL 33141 Max Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Rachel Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Miriam Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 S.F. Land Trust f/b/o Perri Stern Family TRUST NAME • NAME AND ADDRESS %OF STOCK Meredith Rishtu 10% 6565 Collins Avenue, Miami Beach, FL 33141 3. PARTNERSHIP/LIMITED PARTNERSHIP If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHIP, list the principals of the partnership, including general and limited partners. Where the partner(s)consist of another partnership(s), corporation(s),trust(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.* PARTNERSHIP or LIMITED PARTNERSHIP NAME NAME AND ADDRESS %OF STOCK NOTE:Notarized signature required on page 8 7. A ff _am A w L, �2 3 r.�� j 4 y . f.J Miscellaneous Cash Receipt F CITY OF MIAMI BEACH ' . '-ri. No. r7 D Cash 0 Credit Card Check# 17 1 $ 1 14 O - - '0 c. 1 20 /c Received of AA IC. lire\ , L 6, lk I P. Q(e. 6 v (2,, 1 o r t kct / -4- i Address .4)A I For ;(j--,°) Cc1iF,i i.,..; Ain- v PexC'n, rt... /— f ,- \1 <,--,we c fz. . -- r� (THIS INFORMATION MUST BE COMPLETED) Office of Finance Director By. ',,,,..1- Account Number ( k---A;() -7,(f‘-1 LA ti . P Det: C \,„C i ft k EXT: c a l Preparer. ( r ' P illi!4 °C)11118"41ftwiliwip, City or Finance pep mi Be ach_FI artment orida 1533 6 ty Hal 7 6i3-1 12dDec40?2415BR1 ,� $705<,2075 0,D0 09:3B,gM x137 MCR MCRCL ERK I7s#12l2 448 e ck (0400177 . $1050 00 C1er ` Have a n PA1D $1050.00 ice day!