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Bernardo Fort - 500 Alton Road Ventures, LLC Ste. loo Fr'-ro J 0 cT. 1220 6' 4 5 -coy fn q t MIAMI BEACH Office of the City Clerk t, ^^•^, I . , 1700 Convention Center Drive 'I°'.''�Y 23 e''! 4: 23 Miami Beach, FL 33139 305.673.7411 LOBBYIST REGISTRATION FORM - - ‘f. C..- _ Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage. defeat or moditication 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 'hone" 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: Fort Bernardo NAME OF LOBBYIST (Last) (First) (Middle Name) Arquitectonica 2900 Oak Avenue Miami Florida 33133 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 372-1812 argbfb@arquitectonica.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Galbut Russell NAME OF PRINCIPAL (Last) (Fast) (Middle Name) 500 Alton Road Ventures, LLC and 1220 Sixth, LLC c/o Crescent Heights 2200 Biscayne Blvd. Miami, FL 33137 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Cade) (305) 374-5700 rgalbut@CrescentHeights.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(if none,write N/A): Russell Galbut • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A SO OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST(if none,write N/A): See Attached -- Page 1 of 5 Q 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. Development Approvals and Permitting Issues, including, but not limited to the 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 500-700 Alton Road and 1220 Sixth Street, Miami Beach, Florida. 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. r Full Name of Individual and Contractual Relationship(If yes,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 DRB,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. List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance of impropriety(if none, write N/A): 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): - -- SOD/v✓ Page 2 of 5 The following six(6)questions MUST be answered: 1) Pursuant to City Code Section 2-488. entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues': _ Yes X 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 X 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 City Code Section 2-462(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 X No: 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 X No: 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 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s) for whom the campaign consultant provided campaign consulting services within the past election cycle. See Section 2-491 for more information. _Yes X No: 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: _Yes X No: If yes, has it been less than 12 months since the elected oficial(s) whom you provided campaign consulting services was sworn in? 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2-491) 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 X No: 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: _Yes X No: If yes. were you promised or did you receive economic consideration in exchange for campaign consulting services? TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ No Amount Paid$7:)( -- MCR# 1 1i101O Date Paid o ,. 2-3. % Lobbyist Registration Form received and verified by: Jc4£A) S 4 .4.017)A_ Page 3 of 5 F;\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 01-01-18 REG.doc Revised 01/01/2018 VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSA ION DURING THE REPORTING PERIOD.' ` 7 `/ Signature of Lobbyist: ,77 —� _ Date J `'z/i D I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all re oiling requirements. `"5-(-2 // Signature of Lobbyist: �— Date 5 / 2 Z7L ___-_... Signature of Principal: _ Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST:IPRINCIPAL State of-t' `�� ���� State of County of: , :tz;i'�i County of: Sworr to (or affirmed) and subscribed before mea Sworn to (or affirmed)and subscribed before me this �d�aynof� Mal- 2018 by this day of 20 , by �vL NAME OF LOBBYIST NAME OF PRINCIPAL __Produced ID Produced ID //` FORM OF IDENTIFICATION FORM OF IDENTIFICATION =Personally Know nit gil Personally Known ICl/1W *Y _- Signature of Notary Signature of Notary Public Name of Notary, Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped 'may MAMAS LEOYIA ' t. MYCCMMSSION#FF155329 (NOTARY SEA fid (NOTARY SEAL) .$ Es Ibni N,August 2018 tW.' ... Bonded Thru Wan Pude uM.nAkn 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. Page 4 of 5 - Revised 01/01/2018 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 DURING THE REPORTING PERIOD.' Signature of Lobbyist: Date 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 the provisions contained in Chapter 2, Art, VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Date Signature of Principal: n�// � Date kid ryry ;' 1 A VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL PA State of State of T o% to CU County of: County of: �Q;;}pA - � IMIS.> Sworn to (or affirmed)and subscribed before me Sworn to(or affirmed)and subscribed before me this day of 20_, by this day of %$4,. ; 20 j, by IjS-U ( I LC Q(lou { NAME OF LOBBYIST NA E OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION / _Personally Known ✓ rsonally K •wn .�_ ( 1.. IIs' . Signature of Notary Public ig a ublic Name of Notary, Typed, Printed or Stamped Name +f Notary, Ty•ed, Printed or Stamped w "aafc OAYAMI AGUTAR (NOTARY SEAL) (NOTARY S c _ Notary Public Slate of Florida ® Commission#FF 196144 , %toF a My Comm.Expires Mar 16.2019 Bondeathrcugh National No.:ry Assn. ' The term"lobbyisr 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. Page 4 of 5 A " ��, iBEACH City of Miami Beach, 1700 Convention Center Drive. Miami Beach. Florida 33139, wwx_miamibeachegov Office of the Ciry Clerk Rafael E. Granada. City Clerk CityClerk@lmiamibeachfl.gov Tel: 305.673.7411. Fax: 305.673.7254 NAME OF LOBBYIST: Bernardo Fort 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 $5000ant to Section 2-482 the Miami Beach City Code. S/z z/ Signature of Lobbyist Date F,CLERSALLaFORMS'.LOBBY,ST FORMSLobbpst Re9stralion Form Revised DI-01-'8 REG eoc Page 5 of 5 SUPPLEMENTARY DISCLOSURE OF INTEREST Interests in 500 Alton Road Ventures, LLC Percentage of Interest KGM Equities, LLC 100% 2200 Biscayne Blvd. Miami FL 33137 Interests in 1220 Sixth, LLC Percentage of Interest KGM Equities, LLC 100% 2200 Biscayne Blvd. Miami FL 33137 Interests in KGM Equities, LLC Percentage of Interest Sonny Kahn 2004 Irrevocable Trust 37% 2200 Biscayne Blvd. Miami FL 33137 Russell W. Galbut 2004 Irrevocable Trust 37% 2200 Biscayne Blvd. Miami FL 33137 Bruce A. Merlin 2004 Irrevocable Trust 26% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Sonny Kahn 2004 Irrevocable Trust Percentage of Interest Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Child of Sonny Kahn 20% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Russell W.Galbut 2004 Irrevocable Trust Percentage of Interest Child of Russell Galbut 50% 2200 Biscayne Blvd. Miami FL 33137 Child of Russell Galbut 50% 2200 Biscayne Blvd. Miami FL 33137 Beneficiaries of Bruce A. Menin 2004 Irrevocable Trust Percentage of Interest Child of Bruce Merlin 33.33% 2200 Biscayne Blvd. Miami FL 33137 Child of Bruce Menin 33.33% 2200 Biscayne Blvd. Miami FL 33137 Child of Bruce Menin 3333% 2200 Biscayne Blvd. Miami FL 33137 31, E tie q ..,,c, $.o a: El3 • _ _ - N� r N o i I' m 3 0 3 ❑ 3 0 -I A 03y , `o a 3 a m ON N <y _; a = S -1 A m 0 v v _ #,„, m O t co v .. r m . r O s9 Z P. a mxN y m 0 3 0 m N O 0 _. hmi O