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Michael Larkin/Krysztof Karbowski \ i<, i !\ \ /. I n F AC- H i \ i'l ; ,:...,\ i \\i\ ' 1'""\ 1" ! I I ' ~ I ~-F_, City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRA TlON 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 Ordinance 2004-3435. (Last) Michael (First) W. Larkin NAME OF LOBBYIST: (M .I) Bercow & Radell, P.A. 200 South Biscayne Blvd., suite 850 BUSINESS NAME AND ADDRESS (Number and Street) (City) Miami, Florida (State) 33131 (Zip Code) (305) 377-6231 TELEPHONE NUMBER: (305) 377-6222 FAX NUMBER: mlarkin@brzoninglaw.com EMAIL: I. LOBBYIST RETAINED BY: Kryzstof Karbowski NAME OF PRINCIPAL/CUENT: (State) 60662 (Zip Code) 100 Ocean Drive Land, LLC BUSINESS NAME AND ADDRESS 1000 North Milwakee Avenue (Number and Street) Chicaao (City) IL (773) 342-8200 TELEPHONE NUMBER: FAX NUMBER: (Optional) mcm1633@yahoo.com EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] . NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Krystof Karbowski and Kamyar Ghazvini . IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Krystof Karbowski and Kamyar Ghazvini II. SPECIFIC LOBBY ISSUE: Modification of Certificate of Appropriateness for Design; HBP Hearing Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship Mf~ None None IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y, FLA T RA TE OR OTHER). A) LOBBYIST DISCLOSURE: (Required) $360.00 per hour B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $360.00 per hour The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": [J Yes X No: Are YOU lobbyina on a Dresent or oendina bid for aoods. eauiDment or services. or on a Dresent or Dendina award for aoods. eauiDment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": DYes X No: Are YOU lobbyina on a Dendina aDDlication for a DeyeloDment Aareement with the City or aDDlication for chanae of zonina maD desianation or chanae to the City's Future Land Use MaD? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481 above) 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 clerk as required by this section but, shall not be required to pay any registration fees.. D Yes X No: Are YOU reDresentina a not-for-Drofit corDoration or entity without sDecial comDensation or reimbursement. V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. /Yl1 (/\J (/'J , Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: ~ J ~ Signature of Principal/Client: co :g 0 ~ ~ ~ ~ en VI. co 00 U5 -_ c: ~ g g,.~ ~ ;f 0 'E ~' ~~ ~ ~' 1!l 00-- ~~~~ LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID 'f Produced ID D'- Form of Identification Form of Identification K Personally known (Lobbyist) Ii "c.'.<);. /, VII. i'~~ \: AJ.l State of F 0 i 0.,.. S'\t' Sworn). This (l Personally known (Principal) SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn and subscribed before me This '-1 rh day of \~:>-:e,"'L-Yc" 20ce // I l~~<, ,rt ('-jCr'7'i(---''':''~ (j(J'?""(,=:JO,3 Signature of Public Notary - State of Fldrida " Notarization of Principal's signature ure of Public Notary - State 0 lorida Notarization of Lobbyist's signature Annual Registration fee: [ ~;o Lobbyist Registration Form received and verified b~ F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc Revised 12/0B/04 II ~ '" .. .......~ocn ~w~a! 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