Michelle D. Kohler/Ocean-Fairwind LLCm P/~iAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA'T'ION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modifcation 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.
NAME OF LOBBYIST: (Last) (First) (M.I)
•n7s r~ ti, f'S'o L TS
and Street) (City)
Mrg-M! g~ Ft. 33!39
BUSINESS NAME AND ADDRESS
(State) (Zip
b S - 7 7 7 - '7 3 ~ ~ ~S - -7 7 7 --13 `d 4 ~-} ~ G.r>! ~ c[_E' ~ D c ~'slv~ ~ fso eTS . nr ~c7'
TELEPHCNE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
~ as L i nlcauJ ~ ~ Sao /t'i,g-rY! ~~~ ~~-- ~ .3 X35
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
~3a5--77Z- 7373 X6,5-777-`73b`~'
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: r/' L 1~rQ ~. C~-r~}'L~GN I M~"N~~'
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: ,q~~S ~.D ~ /~ Q SO a-TS, /~ C-
II. SPECIFIC LOBBY ISSUE:
/='RrRuJiN/J ~-FUT~- FL-yoD Pu4~N ~'1 ~4/VR~~~I ~~T- ~~~D
Issue to b~ lobbied (Describe in detail): ~ L¢~/ RT! OItJ I~IC} 1 V~~°,
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Narne of Individual/Title 6) Any Financial, Familial or Professional Relationship
Cary .40MrNr5 770
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLATRAIPOR OTHERf
A) LOBBYIST DISCLOSURE: (Required) N~~ ~ D-7~-~° 7~~1 A/O ti°~'''1f3L Crjrl'IPe~t1 S~4TY 0 N
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). NONE OTty~c-~° ~~U N~'eN•L'4"L C~/I'1B~S~~
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 tYNo: 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":
application for chance of zoning map designation or chan~c a to the ~~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 anot-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.,
Yes [~lo: Are you representing snot-for-profit corporation or entity without special compensation
or reimbursement. .
SIGNATURE UNDER OATH:
ON OCTOBER 1~ 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. /)
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 Mia 'Beach City Code and all reporting
requirements.
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Signature of Lobbyist:
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Signature of Principal/Client: ''~ _,-
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VI. LOBBYIST IDENTIFICATION: P NCIPAL IDENTIFICATION:
i Produced ID . ~ Produced ID
Form of Identification _
Form of Identification
personally known (Lobbyist) ~sonally known (Principal)
II. SIGNATURE AND STAMP OF NOTARY: at;~~~'~+b''t
~- tate of Florida, County of Miami-Dade
worn to and subscribed before me
~
State of Florida County of Miami-Dade
~
Sworn and subscribed b
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,R .- his t S day of "SU ~ C , 200 `~
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This 1 S day of ~ ~.l N.1 F
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W i nature of Public Nota
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otarization of Lobbyist's signature Signature of Public Notary -State of Florida
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nnual Registration fee: J Yes [ ] No A ount Pai LY
MCR I Date Paid ~ S
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• obbyist Registration Form received and verified ~ ~
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Revised iZ 08/04
OCEAN-FAIRWIND LLC
DISCLOSURE OF INTEREST
Member Name, Address & Office % of Ownership
Oceanside Resorts, Inc. 100%
605 Lincoln Road, #320
Miami Beach, FL 33139
Disclosure of Interest for Oceanside Resorts, Inc.
Name, Address 8~ Office % of Ownership
David Callen 8%
8870 North Himes Avenue, #242
Tampa, Florida 33614
Robinson Callen Trust A
PO Box 403367
Miami Beach, Florida 33140
Beneficiaries: Claire Callen
c/o Oceanside Resorts Inc.
605 Lincoln Rd, #320
Miami Beach, FL 33139
Lana Callen
865 North Shore Drive
Miami Beach, FL 33141
Robin Callen
1507 West River Lane
Tampa, FL 33603
Casper R. Callen Trust
618 East Broughton
Savannah, GA 31401
Beneficiaries:
Andre Callen
c/o HI Development Corp.
1 1 1 West Fortune Street
Tampa, FL 33602
Sean Callen
c/o HI Development PR
1004 RH Todd Avenue, 3~d FL
San Juan, PR 00907
Ian Callen
c/o HI Development Corp.
1004 RH Todd Avenue,
San Juan, PR 00907
Dorian Callen
PO Box 2669
Winter Haven, FL 33880
Desiree Callen O'Neill
425 Lake Ned Road
Winter Haven, FL 33884
Tarquin Callen
46%
33.3%
33.3%
33.3%
46%
14.29%
14.29%
14.29%
14.29%
14.29%
14.29%
c/o Callen Trust
PO Box 8747
Savannah, GA 31412
Justine Callen Bohannon 14.29%
P O Box 7142
Winter Haven, FL 33883