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Jose L. Gomez - Haim Victor Hayon I o -. t\/\ /\IV\ I BE AC HOffice 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 "n/a" 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: Gomez, Jose L. NAME OF LOBBYIST (Last) (First) (Middle Name) Beilinson Gomez Architects P.A. 8101 Biscayne Boulevard, Suite 309, Miami, FL 33138-4664 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 559-1250 (305) 778-7955 jq a,beilinsonarchitectspa.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Hayon, Haim Victor NAME OF PRINCIPAL (Last) (First) (Middle Name) 1208 Collins Ave LLC 1208 Collins Avenue Miami Beach FL 33139 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 788-6006 excessmia@gmail.com 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: 1.4A-/M �zc r 14/4110A) • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: I (� I V r(G ? -j' t 1 01 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. i 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 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: N/A 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): $250.00 per 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 XNo: 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 member(s)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 ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSATION DU NG THE REPORTING PERIOD.' ? Signature of Lobbyist: ..---7-- Date 63':81 j—] I do solemnly swear or of I that ail of the f egoing facts, statements, and disclosures in this form are true and correct, and that I have read or am iliar it the `rovisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code an.(416 -..king regt}irements. Signature of Lobbyist: Date 03/22/i7 Signature of Principal: t> 2 - ri Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of FOC*IDA State of FL-OR IDA County of: r`(1 I AMI- IY'.i County of: rn I A M I- _b1 Sworn to(or affirmed) and subscribed before me Sworn to(or affirmed) and subscribed before me this'23h" day of mfl(ZcH , 201=1 , by this2V"day of tUAPCki , 200, by UDse L. GOM Z -IAN 11 VIcTb +iAyot.. NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION Personally Known �( Personally Known ` t, -_ k Signature f NotaryPublic Slgnatu of Notary Public 111M ' -E L: \)Z=f1<)nK1 MRRL(— EVE VE.1ZIE. -- Name of • - - ' - Name of Notary, Ty--- . • -• • - •• -- a MARY-EVE VE '' ES a MARY-EVE VENDRYES ,�t�.PY PL6 i ••NI"" (NOTARY .'tin Notary Public-State of Florida •; �°w�aI (NOTARY SEAL) r L Notary Public-State ol Florida I .My Comm,Expires Jun 17,2017 'tt :� `s Commission#FF 010215 Nj; , MtI!Comm.Expires Jun 17,2017 ' '•,�or� •° -.,,� d a Commission 0 FF 010215 9 „"„ 8°11611* o .; e':‘,".mr� ' BY CITY CLERK'S STAFF ONLY ''1n nn��`s Bonded Through National Notary Assn. I r.r Annual Re istrati.n -e: esAmount -ai.$ _ os" MCR# IL Lobbyist Registration Form receive• and verified by: _),", -Al 5': - •n-G- 64, I O F:\CLER\SA,LL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08.18-1G REG.c±oc Revised 08/18/2016 ' 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. 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: Jose L. Gomez 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 October 1 of each year, and the fee for such annual registration shall be $500.00 pur want to Section 2-482 of the Miami Beach City Code. 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