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Justin Karr - Neil and Elizabeth Rosen • G 6 4 9. 1—A- C,e,rtc, Dg-tVE.,- City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 2016 FEB -°3 PM 14: C8 LOBBYIST REGISTRATION FORM -r 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. Karr Justin NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell&Fernandez, PLLC, 200 South Biscayne Boulevard, Suite 850, Miami, FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-377-6225 305-377-6222 JKarr( ,,BRZoningLaw.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: Neil and Elizabeth Rosen NAME OF PRINCIPAL/CLIENT: 5642 La Gorce.Drive Miami Beach FL 33140 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-776-1414 nrmb(a�att.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: N'4. • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: MA- II.SPECIFIC LOBBY ISSUE: Develop enm t Approvals and Permitting Issuesi including, but not limited to the Board of Adjustment, Historic Preservation Board,—Design Review BoardT Planning Board;'Land Use Development Comm.ittee, City Commission, and any City Workshops or Committees, if necessary, relating to the propertu located at C5-6-42 La Gorce Drive,Miami Beach,Florida.) Issue to be lobbied(Describe in detail): Ill. 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. None. None. C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc 6 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$235.00 per hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $235.00 per hour_ (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 XNo: Are you lobbvina on a present or pendina bid for aoods.eauipment 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)No: Are you Iobbvina 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 JC 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 L OMP NSATION RECEIVED. IN THE CITY OF MIAMI BEACI{ EQB THE PRECEDING CALENDAR YEAR. A STATE NT - ALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPOR IN P IOD. r Signature of L•.byist I do solemnly swear that all of the foregoing fact- re tru and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code a r:sorting requirements. Signature of Lobbyist: , re.,-' � s Signature of Principal/Client: � / / �/, �� "".'''' --INCIPAL IDENTIFICATION: VI. LOBBYIST IDENT� ICATION: '� ;�,;d�e.w`ol� �` Produced ID �/ !0c'? ' Produced ID Form of Identification ""•„0.,a»' ''' Form of Identificeti MoMM/0/0 N‘ NE H.MOSS Ca \\\ 0 ........ C,p �i Personally known(Lobbyist) ni 0 o t Personally known(Principp�;�o�Mobef�NF./A�•O,o B ..� "� S29 .. VII. SIGNATURE AND STAMP OF NOTARY: H' 3 g g. T . e : cQ ��u' •fi - °• . r #FF 054074 e Q State of Florida, County of Miami-Dade -a cn r- State of Florida, County of Mi iie ade . o� Sworn to - d subscrib b-fore me �+ " Sworn nd ubscri•-•/before nt.—� �rdedkh N��,:e 0:, d q .` P/clary .• �t a This da of �J ° g a This � ay of ;- , 'Ar,.�s••ni.. pF��\ .. ��I cnwo sr���lP�i011 11���\\\ I-l �� 4 - Signatu - •f Pus.-0 No ary—State of Florida ao d V Signature of'l•lic Notary—State of Florida Notarization o .bbvist's signature ' Notarization of principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ No Amount Paid$ •C MCR# _140i 6b3 _ Date Paid 0:1-0S, It Lobbyist Registration Form received and verified by _ N)S4ivll o,a MIAMI.Am I BEAc H 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: Justin Karr 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 $50.00 a day shall be assessed for all Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the assessed fines after notification. Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. 1/6 Signature Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Miscellaneous.'Cash`Recei - t :i .Y A 2 _, f 3 :46 b -1-,� CITY OF M1�1111fI BEACH _ ,<. x F .' i=t.' 1 ;� 1: 5($;�JO• z X34, F P !� -`T�+' 4...,:-....,,:r.,,-;;„-.,-..,,:,,-,-„,::=.;. ( ) 'r 4' �� a ❑ 'Cash 0 Credit Card - . _ Check# _ 1•-4.,„•-,, -,-.._-:-.-;::::',,..,:::_,,:,, ...:-..io:,.../:.:1- ; ( } Received of $�ri1J. :/6 , _ -- ti•:Address / g ac:. P.,V e r t= 1 •c�T€-` , '_ fi_ L , r r For.. r ;'-'--.. •--',--;--;',:•--;.;-::: . ' THIS INFORMATION MUST-BE COMPLETED) ' Office of Finance Director -,.j; i. ,"_ r By t �; Account Number. 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