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Jose L. Gomez - David Wallack Real Estate LLC 900 C -ec IV\IAtv'\I BEACH Office of the City Clerk JUN 14 2021 1700 Convention Center Drive Miami Beach, FL 33139 305.673.7411 CITY OF MIAMI BEACH LOBBYIST REGISTRATION FORM OFFICE OF HE CITE CLERK 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 jg@beilinsonarchitectspa.corn LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Wallack, David NAME OF PRINCIPAL (Last) (First) (Middle Name) David Wallack Real Estate LLC 900 Ocean Drive Miami Beach, FL 33139 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-673-4422 dw a`nangos.corn 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): See Attached. • 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): Page 1 of 5 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 Historic Preservation Board, Planning Board, Board of Adjustment, Land Use Development Committee, Citu Commission, and anti Citu Workshops or Committees, if necessart./, relating to the propertu located at 900 Ocean Drive, 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 Stafffor the Planning Department, Building None X Department, Public Works, and City None X Administration, PB, BOA, DRB, City None X 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 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): $250.00 per hour 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 2-482(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 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_No:• If yes, has it been less than 12 months since the elected official(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_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 / 7 Annual Registration fee: [ ]Yes f1]No Amount Paid$ 3 5O.c3' MCR# t,lj1�1 J ` Date Paid Ov I Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 01-01-13 REG.doc Revised 01/01/2018 Page 3 of 5 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 ENGAGEDTO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENS; , D :. .G THE REPORTING PERIOD.' Signature of Lobbyist: (---r- Date 0x4 011�� 1 I do solemnly swear or athat -II of the fr regoing facts, statements, and disclosures in this form are true and correct, and that I have read or miliar , ith the •rovisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and - -•ortin: requirements. Signature of Lobbyist: 41111111ADate CYAci ( Zo 24 Signature of Principa• W�j �� A late i '6 /•d ifl VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL . State of FLQR/l) q State of /'A DX I D A' County of: IMAM/—. 44. County of: P,1 Pt's Sworn to(or affirmed)and subscribed before me Sworn to(or affirmed)and subscribed before me this ' 'h day of 0(.10 202-1 .. 9, by this /eday of 11.)1/1% , 2019, by Z'o s>✓ t_L . G aM.E.-�___ j A VIP e4/s9/I n C/C' NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION Y___Personally Known personally Known it . . l. • _ _:,_ ► • Signature(• f Notary Public— +ALM Signature of Notary ub c MAR`( -EVE 'VETAA L 6s 5- ct/V1:-. 11,6-4/0(7/1141}V Name of Notary, T ped, Printed or Stamped Name of Notary,Typed, Printed or Stamped ,•4*p�p"�•.� IdARY�VE VENDRYES , .� Notary PuMu:— de YEs•da (NOTARY S •e Commission ti GG01i M (NOTARY SEAL) .,� ��: My Comm.Expires Jun 17,2021 I . N � , JUNE F+ENDER50 ••Eos rtscam trough MOW TY, + 467--...1,:l Nc:a^.v:,it•State:f Florida iy. s Cam—limy c 13777 1 ? =/ eiy Comm.uucves Oct 7,2024 I Bonded through National Notary Assn, I 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. Page 4 of 5 MIAMi BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachil.gov Office of the City Clerk Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov Tel: 305.673.7411, Fax: 305.673.7254 NAME OF LOBBYIST: Jose 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 commencin. October 1 of each year, and the fee for such annual registration shall be $500.00 purs ant to Section 2-482 of the Miami Beach City Code. O(b(I ) �?.A2 t Signature of Lobby-t Date 1 F.\C RVSALL1aFOR S110138YlST FORMS\Lobbyist Registration Form Revised 01-01-18 REG doc Page 5 of 5 Page 6 of 8 filed, but prior to the date of a final public hearing, the applicant shall file a supplemental disclosure of interest. DISCLOSURE OF INTEREST CORPORATION, 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 liability 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 individual(s) (natural persons) having the ultimate ownership interest in the entity. • David Wallack Real Estate,LLC-900 Ocean Drive,Miami Beach,Florida 33139 NAME OF CORPORATE ENTITY NAME AND ADDRESS %OF OWNERSHIP David Wallack, Manager 2% 900 Ocean Drive Miami Beach, Florida 33139 Wallack Irrevocable Trust fbo Joshua Wallack 49% Wallack Irrevocable Trust fbo Janna W.C. Kowan 49% NAME OF CORPORATE ENTITY NAME AND ADDRESS %OF OWNERSHIP 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. We are committed to providing excellent public service and safety to all who live,work,and play in our vibrant,tropical,historic community. • Page 7 of 8 DISCLOSURE OF INTEREST TRUSTEE If the property that is the subject of the application is owned or leased by a trust, list any and all trustees and beneficiaries of the trust, and the percentage of interest 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 individual(s) (natural persons) having the ultimate ownership interest in the entity. Wallack Irrevocable Trust fbo Joshua Wallack TRUST NAME NAME AND ADDRESS % INTEREST Joshua Wallack 100% 8126 International Drive Orlando, FL We are committed to providing excellent public service and safety to all who live,work,and play in our vibrant,tropical,historic community. Page 7 of 8 DISCLOSURE OF INTEREST TRUSTEE If the property that is the subject of the application is owned or leased by a trust, list any and all trustees and beneficiaries of the trust, and the percentage of interest 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 individual(s) (natural persons) having the ultimate ownership interest in the entity. Wallack Irrevocable Trust fbo Janna W.C. Kowan TRUST NAME NAME AND ADDRESS % INTEREST Janna W.C. Kowan 100% 10 Friendship Street Tivoli, NY 12583 Ne ore committed to providing excellent public service and solely to all who live,work,and play in our vibrant,tropical,historic community • Miscellaneous Cash Receipt CITY OF MIAMI BEACH No, 428131 O Cash. , [7 Credit Card C Chedc# S .) 4. , try 20 . �C.w.a of Miscellaneous-MCK-2021 OiMOPLIPFt Ai3 V17 err461102:0©F` S , e :,� '1 1 44" i For,, C;xrx J€ 2 k ist'c� P (ayment Amount: 350.00 r t ar. (THIS INFORMATION MUST BE COMPLETED) Office of MUM'Director By Mco not Nth: ( 1 •� [) 'lvS{jf preparers, .: ' ,,+.,} 4'J,�§ .,,-1-" t' (- `w„,_ EXT: L f t `