Neisen Kasdin - Carillon Hotel, LLC 6$0 co it(eLy
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ARA EAC Office of the City Clerk
1700 Convention Center Drive
Miami Beach, FL 33139
305.673.7411
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 City Code Chapter 2,Article VII, Division 3,entitled"Lobbyists,"
for additional information.
Instructions: Please complete all sections of this form and submit the completed form,with the applicable fee,to the Office of the City
Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular
section, you must write "none" or "nia" in that section. Any change to any information originally filed, or any additional City
Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form.
The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs.
Separate registration forms shall be required for each principal represented on each specific issue.
I. LOBBYIST INFORMATION:
Kasdin Nelsen
NAME OF LOBBYIST (Last) (First) (Middle Name)
Akerman LLP,Three Brickell City Centre, 98 Southeast 7th Street, Suite 1100, Miami, Florida 33131
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)374-5600 neisen.kasdin@akerman.com
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
Carillon Hotel, LLC
NAME OF PRINCIPAL (Last) (First) (Middle Name)
The Carillon Hotel, 6801 Collins Avenue, Miami Beach, Florida 33139
PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(847) 235-8100
PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code
Section 2-482(c):
• NAME OF CHIEF OFFICER, PARTNER,OR BENEFICIARY: See attached.
• NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: c ac hvt •
Gl
III. ISSUE TO BE LOBBIED:
Describe with as much detail as is practical,including but not limited to a specific description where applicable of a pending request for
proposal,invitation to bid,or public hearing number.
Variance to operate and utilize its accessory outdoor bar counter between the hours of 8:00 p.m. and midnight, and all
other land use, zoning, development, and licensing matters related to the property commonly known as6801 Collins Ave.
IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4),list the City Commissioner or City personnel sought to be lobbied,and whether the
lobbyist has entered into any contractual relationship(paid or unpaid)with said City Commissioner or City personnel from 12
months preceding such commencement of service with the City to the present date,stating the general nature of the subject
contractual relationship.
Full Name of Individual and Contractual Relationship(If yes,explain) YES NO
Title of Person to be Lobbied
City of Miami Beach HPB None X
Planning Director&Staff 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.
List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance of
impropriety:
None
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION - Be Specific. (Note that a
contingency fee is prohibited pursuant to City Code Sec. 2-485.3):
$725/hour
The following five(5)questions MUST be answered:
1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues":
_Yes z.No: 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 City Code Section 2-490,entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development
Issues":
—Yes XNo: 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 City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in
Section 2-481)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 city clerk as required by this section,but shall not be required to pay any registration fees.
_Yes XNo: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement?
4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who
provide only scientific,technical or other specialized information or testimony in public meetings; any person who only appears
as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct,
indirect or contingent,to express support of or opposition to any item;and any person who only appears as a representative of
not-for-profit community based organization for the purpose of requesting a grant without special compensation or
reimbursement for the appearance.
_Yes XNo: Are you providing only scientific, technical or other specialized information; appearing as a
representative of a neighborhood association without special compensation or reimbursement or
representing a not-for-profit based organization for the purpose of requesting a grant without
special compensation or reimbursement?
5) Pursuant to City Code Section 2-482(a)(4), a lobbyist who has within the past election cycle provided campaign consulting
services to an incumbent member of the City Commission shall disclose such particular service on his/her lobbyist registration
form and shall orally disclose such particular service before lobbying the City Commission at a public meeting.
_Yes XNo: Have you provided campaign consulting services to an incumbent member of the City Commission
within the past election cycle?If yes,please list the incumbent members}of the City Commission:
If yes,you must also orally disclose such particular service before lobbying the City Commission at a public meeting.
VI. SIGNATURES UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED STATEMENT UNDER OATH. LISTING LOBBYING EXPENDITURES. AS WELL AS COMPENSATION
RECEIVED. FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGE► r LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO
EXPENDITURE OR COMPENS • , 'URING THE REPORTING PERIOD.'
Signature of Lobbyist: � Date q
I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct,
and that I have read or am familiar with t provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of
the Miami Beach City Code and al re ' g quirements.
Signature of Lobbyist: Date 2, I 01-
Signature of Principal: ....,4‘.[..---;,--4111111111111111111111111°
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VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: ,/� (�,� PRINCIPAL
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State f ,�1\ `� State of #4-2-ec-✓ kk
County of: 1 ' b \' wt. County of A-4'(. ) X i 1 _
Swo4 0(or affirmV a d subs r ed before m --1 Swornnttd(or affirmed)and subscribed before me
this day of � ,201 jby this it.day of 7----c 5c� '7 ,2011 by
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NAM F LOBBYIST NAMME OF PRINCIPAL sco,
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FORM OF IDENTIFICATION FORM OF IDENTIFICATION
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Diana Perez-Geta q ' 0 0.v,w H
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Name of Not- : }•' •9P Name of Notary, Typed, Primed or Stamped ty 3 a
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(NOTARY SEAL ” ExPires 6/8/2019 (NOTARY SEAL)
TO BE COMPLETED BY CITY CLERK'S STAFF ONV6
Annual Registration fee: [ ]Yest14 No Amount Paid$ 3115'd90 CR# d4/3 K01 Date Paid O Z- (U- 17
Lobbyist Registration Form received and verified by: 91'1.AV,' oa-(/
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc Revised 08/18/2016
1 The term"lobbyist"specifically excludes the following persons:
Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings;any person who
only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether
direct, indirect or contingent,to express support of or opposition to any item; and any person who only appears as a representative of
not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for
the appearance.
OWNERSHIP DISCLOSURE AFFIDAVIT
lo*STATE OF eo )
+ )ss:
COUNTY OF &feu yof IG >
Before me, the undersigned authority, this day personally appeared James J. Zenni, Jr.,
Manager of Carillon Hotel, LLC, f/k/a Z Capital Florida Resort, LLC, and President and Chief
Executive Officer of Z Capital Group, LLC and Z Capital Partners, LLC, member of Z Capital
Partners UGP, L.I,.C., Z Capital Partners GP II, L.P., the General Partner of Z Capital Partners
Il-A, LP, Z Capital Partners II-B, LP, and Z Capital Partners II, LP ("Affiant"), who being by me
first duly sworn, upon oath, deposes and says:
1. That I am the Manager of Carillon Hotel, LLC f/k/a Z Capital Florida Resort, LLC
("Carillon"), the applicant submitting the accompanying application for a public hearing
before the City's Historic Preservation Board ("HPB") as required by the City of Miami
Beach's ("City") Land Development Regulations for the Certificates of Appropriateness
and Variances to be issued under HPB File No. 7624 affecting the real property located in
the City described in the aforesaid application made a part hereof.
2. That Carillon is a wholly owned subsidiary of Z Capital FR Holdings, LLC ("FR
I loldings"), the ownership interests of which are held in limited partnerships managed by
Affiant wherein no one natural person holds a total of Five Percent (5%) or more of the
ownership interests in the applicant entity.
3. That the facts stated in this Affidavit, and represented in the application and documents
submitted in conjunction with this Affidavit, are true and correct, to the best of the
Affiant's knowledge, information and belief.
Further Affiant sayeth not. ,,
ellitak
James J.Zenni dri
Manager of Carillon Hotel, LLC, f/k/a Z Capital
Florida Resort, LLC
President of Z Capital Group, LLC and Z Capital
Partners,LLC
Authorized Signatory of Z Capital Partners UGP,
L.L.C. and Z Capital Partners GP II, L.P., on behalf
of Z Capital Partners II-A, LP, Z Capital Partners
II-B, LP, Z Capital Partners II, LP and Z Capital FR
Holdings, LLC .y
The foregoing instrument was sworn and subscribed before me this p�-7' day of
ec�eer, 201 by James J. Zenni, Jr., Manager of Carillon Hotel, LLC f/k/a Z Capital Florida
Resort, LLC, and Authorized Representative of Z Capital Group, who produced Florida Driver's
License Z500-450-55-022-0 as identification.
FIVI ,..- Notary Public
NOTARY PUaTTBLICEWDASTATE OfDKRNE NEW YORK
{40242657j}} OUAURED IN NEW YORK COUNTY
MY COMMISSION EXPIRES OCT 1 2019
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov
Office of the City Clerk
Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov
Tel: 305.673.741 1, Fax: 305 673.7254
NAME OF LOBBYIST: Neisen Kasdin
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT
Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or
principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement
(Statement). In addition to any other penalties that may be imposed as provided in
Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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 of each year, 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.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
signed Statement under oath listing all lobbyist expenditures, as well as compensation
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I understand annual registration of all lobbyists shall be required for each 12-month period
commencing c - ober 1 of each year, and the fee for such annual registration shall be
$500.00 ; >1*' to Section 2-482 of the Miami Beach City Code.
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Signature of Lobbyis Date
F.ICLERISALL1eFORMSILOBBYIST FORMS1Lobbyist Registration Form Revised 08-18-16 REG.doc
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