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Carter McDowell/Savoy Hotel Partners, LLC (2) 1125. City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 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 Ordinance 2004-3435. Deas NAME OF LOBBYIST: (Last) Alexandra (First) L. (M.I) Bilzin Sumberq Baena Price Axelrod LLP 200 S. Biscavne Blvd. Suite 2500 Miami. Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) Zip Code) 305-350-7241 TELEPHONE NUMBER: 305-351-2176 FAX NUMBER: adeas@bilzin.com EMAIL: I. LOBBYIST RETAINED BY: Savoy Hotel Partners. LLC NAME OF PRINCIPAL/CLIENT: Savoy Hotel 425 Ocean Drive. Miami Beach, Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 786-866-0071 TELEPHONE NUMBER: FAX NUMBER: (Optional) 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: . IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Extension of time to obtain a buildinq permit for Torino/Savoy Beach Club 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 Miami Beach Historic Preservation Board and None staff IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER) A) LOBBYIST DISCLOSURE: (Required) Hourlv $240.00 B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Hourly $240.00 MIAMI 1207949.1 7653024060 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": - Yes QgNo: 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 Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": J Yes Qg No: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoning man designation or change to the City's Future Land Use Map? 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.. IJ Yes QgNo: Are you representing a not-for-profit corporation or entity without special compensation 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/7 / ~ ~a h 7::>c-~ 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. tJy;~ ~ Signature of Lobbyist: Signature of Principal/Client: ~ VI. LOBBYIST IDENTIFICATION: lfJ1)) o Produced ID Form of Identification [!( Personally kno , <I l~V.f~,~.< MERCEDES PADRON VII. SIGNATURE AND s\Tl~L'~ rti~~~ION#DD608768 ~. ',::A~.I'''' ~~m:Wovember9,2010 {, '':~,];~' ~~,,, Bonded Thru Plchard Insurance Agency State of Florida, County iSf'Mf" Sworn to and sub ribed before me hi day of , 20a.((L r>t- Sig ature of Public Notary - State of Florida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: I Produced ID Y:tG. U(uQ,(s ~ I cense Form of Identification o Personally know i ....~i.~tf~~< MERCEDES PADRON , ; ~:~. i!J:.., i'~ MY COMMISSION # DD 608768 .,,:;~~~~~ EXPIRES: November 9, 2010 State of Florida, Coun " '- hru PlCha,d Insurance Agency Sworn and subscr' ed before me . ~ day f "en Y ~3pOf.c, Sig ature of Public Notary - State of Florida Notarization of Principal's signature / FOR CLE~~l,hSE ONL y2 Annual Registration fee:#Yes [ ] No Amount Pai&C';;';'-MCR #/Date Paid Lobbyist Registration Form received and verified by: oJ Co ~f5 F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST FORM 05.Ct ~- ,J D- J to ( ()(o Revised 12/08/04 eMe(~ \2.{ C# OU~6 r,,', C' '- (') ",::-' '-{Y'. . 'L~ MIAM11207949.17653024060 Disclosure of Ownership Interest for Savoy Hotel Partners, LLC Savoy Hotel Partners, LLC, a Florida Limited Liability Company 7307 Somerset Shores Orlando, FL 32819 A. Officers Savoy Hotel Management I, LLC, a Florida Limited Liability Company, Manager 455 Ocean Drive Miami Beach, FL 33139 B. Ownership Savoy Hotel Management I, LLC, a Florida Limited Liability Company 455 Ocean Drive Miami Beach, FL 33139 1. Officers Avi Werjuka, Manager 455 Ocean Drive Miami Beach, FL 33139 11. Ownership a. Savoy Hotel Management, Inc" a Florida Corporation 455 Ocean Drive Miami Beach, FL 33139 (i) Officers A. Avi Werjuka, President 455 Ocean Drive Miami Beach, FL 33139 B. Gary Cohen, Secretary 455 Ocean Drive Miami Beach, FL 33139 (ii) Directors A. Avi Werjuka, President 455 Ocean Drive Miami Beach, FL 33139 B. Heller, Director 455 Ocean Drive Miami Beach, FL 33139 C. Michelle Dryer, Director 103 Foulk Road, Suite 200 Wilmington, DE 19803 (iii) Ownership A. Avi Werjuka 455 Ocean Drive Miami Beach, FL 33139 100% b. Savoy Hotel Partners I, LId" a Florida Limited Partnership 455 Ocean Drive Miami Beach, FL 33139 (i) Partners and Ownership A. Savoy Corporate Management, lnc, a Florida Corporation General Partner c/o KDC 201 S, Biscayne Blvd, # 1500 1% I. Officers MIAMI 958608,3 7653024060 1% 99% 100'1., 100% 100% MIAMI 958608.3 7653024060 A, II. Ownership A. The Amelin Trust a British Virgin Isles Trust (i) Ownership (a,) Avi Werjuka Beneficial Owner (b,) Lexinter Management, Inc, Trustee B. The Amelin Trust a British Virgin Isles Trust Limited Partner I. Ownership (a.) Avi Werjuka 100% Beneficial Owner (b,) Lexinter Management, Inc, Trustee c. Jaymar Savoy Estate Company a Trust Limited Partner I. Ownership (a,) Mark Halpern Beneficial Owner (b.) Mordechai Halpern Trustee 100% 100% 100% 80% 19%