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Michael W. Larkin - Mansouranco, LLC -1 L13 hcr,„ , , DocuSign Envelope ID:CD3E8CE8-3D00-4202-BBD5-8EF9555CDBOF RECEIVED MIAMI BEACHAPR212, �;.( Office of the City Clerk 1700 Convention Center Drive 'CITY OF Mm.%�' Miami Beach, FL 33139 kOFFICE OF}"HF 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: Larkin Michael W. NAME OF LOBBYIST (Last) (First) (Middle Name) • Bercow Radell Fernandez Larkin&Tapanes,PLLC 200 South Biscayne Blvd.,Ste. 300 Miami,Florida 33131 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)374-5300 mlarkin@brzoninglaw.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Mansour Jonathan NAME OF PRINCIPAL (Last) (First) (Middle Name) Mansouranco, LLC 600 NE 27 Street Miami Florida 33137 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) jonathan.mansour@hotmail.fr PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS o Pursuant Qj City Code Section Y4`8n (1)(a): A principal of faky corpo ation partnership CV other entity who appears Epp lobbyist Ca1 behalf of tha entity.iallmfie special compensation Ct7oditEmEgiM fornQ'b- appearance,hie nen C Imo,C2 contingent,ajoiroxamaMplICOCIeoe sosifion tE, an item shall register with the Crlerk as required by this subsection but sh. II riot be req Led to pay any registration fees. 0 If the principal is a Corporation,' Partnership or Trust, the following information MUST be provided pursuant to City Code Section 2-482(c): W • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(if none,write N/A): Jonathan Mansour L'7*_ LL • NAME OF ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,PARTNERSHIP OR TRUST(if none,write N/A): please see the attached. LL 0 LL Page 1 of 5 �•aa ,AF-69A9CE357D4C 'III M'I III Page 1 of 5 169A9CE357D4C , DocuSign Envelope ID:CD3E8CE8-3D00-4202-BBD5-8EF9555CDBOF 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 &Planning Issues,including but not limited to the Historic Preservation Board, Design Review Board,Planning Board,Board of Adjustment,Land Use Development,City Commission, and any City Workshops or Committees,if necessary,relating to the property located at 743 Washington Avenue in 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. Full Name of Individual and Contractual Relationship (If yes,explain) YES NO Title of Person to be Lobbied Staff for the Planning&Building Department None X Public Works &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. N List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an • appearance of impropriety(if none,write N/A): None U W U rn • 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): 695 per hour n LL o Page 2 of 5 DocVerify IDdocverify.com:D5F7DCE7-15FC-0072-RCAF-69A9CE357D4C FFF�� Page 2 of 5 I 269A9CE357D4C ,III 41 I III Awww. DocuSign Envelope ID:CD3E8CE8-3D00-4202-BBD5-8EF9555CDBOF 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 2-482(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 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 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: _Yes XNo: f yes, has it been less than 12 months since the elected official(s) whom you provided campaign onsulting services was sworn Ini. 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting g 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 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: 0 0 U _Yes XNo:• If yes, were •,o. a romiseo or did you receive economic consideration in exchange for campaiq coonsultingTe�r1viae f • LL STAFF ONLY TO BE COMPLETED BY CITY CLERK'S 1j L Annual Registration fee: [ )Yes[--0 No Amount Paid,$ 35" MCR# _1 T� ;, 1 Date Paid D 4-21• G� LL Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist.Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 0LL Page 3 of 5 DocVerify ID:D5F7DCE7-16FC-4072-8CAF-69A9CE357D4C I Page 3 of 5 369A9CE357D4C I ,III III L, www.docverify.com DocuSign Envelope ID:CD3E8CE8-3D00-4202-BBD5-8EF9555CDBOF • 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 COMPR-NSAEIONiDURING THE REPORTING PERIOD.' Signature of Lobbyist: Date 4/20/2021 -32B2B355D9E6410... 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 regUit ialer'ts. Signature of Lobbyist: by: Date 4/20/2021 C Docuslgoea32821333509E0410... Signature of Principal: Date 4/20/2021 13134A1391E13111-1413E1... VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of Florida State of Florida County of: Miami-Dade County of: Miami-Dade Sworn to(or affirmed)and subscribed before me, Sworn to(or affirmed)and subscribed before me, by means of❑ physical presence by means of❑ physical presence or® online notarization, or ID online notarization, this 20 day of April ,2021, by this 20 day of April ,2021, by Michael W.Larkin Jonathan Mansour NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X Personally Know x Personally Known _.... 65 - b]+fmNMAVAf]o.fesm �Sgwm FlLOVAI]o,leam Signature of Notary Public Signature of Notary Public 0 Diana Ramos Diana Ramos N Name of Notary,Typed, Printed or Stamped Name of Notary,Typed, Printed or Stamped 0 lana Ramos 1 Diana� Ramos Commission#GG 308355 1 commission#GG 308355 Notary Public-State of Florida 1 Notary Public-State of Florida Igy Commission Expires Apr 10,2023 ► I.y Commission Expires Apr 10,2023 • 1 The t4 persons: spm. �5E,8, s ,o,ao=: _ _�_ Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings;any person who -48 LL 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 DocVerify ID:D5F7DCE7-16FC-4072.8CAF-69A9CE357D4C Page 4 of 5 469A9CE357D4C 'III S ,I II www.docverify.com . DocuSign Envelope ID:CD3E8CE8-3D00-4202-BBD5-8EF9555CDBOF MIAMI BEACH 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: Michael W. Larkin 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 0 understand annual registration of all lobbyists shall be required for each 12-month period N commencing October 1 of each year, and the fee for such annual registration shall be $500.00 pursuant to Section 2-482 of the Miami Beach City Code. DoeuSigned by: 4/20/2021 Signature of LoDDy sre41u Date 0 LL F:ICLERI$ALL1aFORMSILOBBYIST FORMSU.obbyist Registration Form Revised 03-11-20 REG.doc LL Page 5 of 5 DocVerify ID:D5F7DCE7-16FC-4072.8CAF-69A9CE357D4C Page 5 of 5 569A9CE357D4C ,III d www.docverify.com Page 6 of 8 DISCLOSURE OF INTEREST CORPORATIONS, PARTNERSHIP OR LIMITED LIABILITY COMPANY If the property that is the subject of the application is owned or leased by a corporation, partnership or limited Mobility company, list ALL of the owners, shareholders, partners, managers and/or members, and the percentage of ownership held by each. If the owners consist of one or more corporations, partnerships, trusts, partnerships or other corporate entities, the applicant shall further disclose the identity of the individuals) (natural persons) having the ultimate ownership interest in the entity. • JAMESTOWN PREMIER 755 WASHINGTON AVENUE LLC(OWNER) NAME OF COCl}RPOt r:T ENTITY NAME AND ADDRESS %OF OWNERSHIP SEE ATTACHED OWNE . IDDSCL .SUREE AFRO VIT MANSOURANDCO LLC (TENANT) NAME OF CORPORATE INTITTY NAME AND ADDRESS %OF OWNERSHIP JONATHAN MANSOUR, 600 NE 27 ST, MIAMI, FL 33137 100 If there are additional corporate owners, list such owners, including corporate name and the name, address and percentage of ownership of each additional owner, on a separate page. .1kvi D APR ?,1 2021 We are committed to providing excellent public service end safety to all who live.worn.and play in our vibrant,tropical.historic community. ;{iVOFf'•, =';i\'l OF-FICE OF-;-I.t - 17rRK , / iFdoc1erify (( ? ! ) • V E%_% Lobbyist Registration Form - MWL - signed.pdf DocVerify ID: D5F7DCE7-16FC-4072-8CAF-69A9CE357D4C Created: April 20, 2021 12:59:28 -8:00 • Pages: 5 Electronic Notary: Yes / State: FL This document is a DocVerify VeriVaulted protected version of the document named above.It was created by a notary or on the behalf of a notary,and it is also a DocVerify E-Sign document,which means this document was created for the purposes of Electronic Signatures and/or Electronic Notary.Tampered or altered documents can be easily verified and validated with the DocVerify veriCheck system. Go to www.docverify.com at any time to verify or validate the authenticity and integrity of this or any other DocVerify VeriVaulted document. k. • E-Signature Summary .E-Signature Notary:Diana Ramos(dra) April 20,2021 13:01:16-8:00[2D5E181C4050][162.244.152.118] dramos@brzoninglaw.com .a ' Ir r 111 I } t I r�t 1111111 111111 MI 111111 IIII 1111111111111111 IIII 11111 11111 11111 11111111 DocVerify documents cannot be altered or tampered with in any way once they are protected by the DocVerify VeriVault System.Best viewed with Adobe Reader or Adobe Acrobat. All visible electronic signatures contained in this document are symbolic representations of the persons signature,and not intended to be an accurate depiction of the persons actual signature as defined by various Acts and/or Laws. DocVerify ID:D5F7DCE7.16FC-4072.6CAF-69A9CE357D4C ,III g�c 'I 111 www.docverify.com Generated Cover Page 69A9CE357D4C G�C4�" e Miscellaneous Cash Receipt ; CITY OF MiAMi BEACH No, 427684 Q Cash C]Credit Card Check# �)41 z , '#\L A1C:.01 14,,i,,,,„..,• 7 f1Alc, C' , � __ j feed of ° . isce aneous MLt-tl z011 ,,; '°,r4 ave: -V flv t ,? ( 'uL .a*' ''>> 0 4 Ms�ia .71' Dd12`Pill 10'1 i - i 'Wail 114\11)4N Si Payn�enr xrpount # 7oa.UO 1 (THIS PWORMAT)ON MLI5T BE COMPLETED) Ottic�of anc�Dtr�ctor 1 / 1 ° 0-50- -- ) # O t} �t. Account Number