Michael Madden/Plaza Hotel LLC~ MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist mearu all persons employed or retained, whether paid or not, by a pnndpal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or derision of any rnmmtssioner; any action, decision, recommendation of the
City Manager or any rity board or committee; or any action, decision or recommendation of arty city personnel during U-e time
period of the entire derision-malting process on such action, derision or reoxr-menda#~n that foreseeabty wits be heard or reviewed
by the dty commission, ~ a aty board or corr-mittee. The term specifically i~udes the pnnripal as well as any employee engage
in lobbying activities. The toerm "Lobbyists' has speai9c exdusions. Please refer to Ordinance 2004-3435.
M~den Michael
NAME OF LOBBYIST: (Last) (First) (M.I)
Shulman + Assodates 100 NE 38 Street, #2 Miami, Ronda 33137
BUSINESS NAME AND ADDRESS (Number and Street) (Gty) (State) (Zip Code)
(305) 438-0609 (305) 438-0170 michaei@shuiman-design.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
Plaza Hotel, LLC
NAME OF PRINQPAL/CLIENT:
1691 Mitfiiaan A Suite 320 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (Gty) (State) (7p Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL' (Optional)
Fill out t3~is section if PrindPai is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Jakob Kosiba, President of Ocean Drive, Inc., the Managing
Member of Plaza Hotel, LLC
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°Y6 OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: See attached Exhibit B.
II. SPECIFIC LOBBY ISSUE:
Redevdopmerrt of 418-422 & 426 Meridian Avenue
Issue to be lobbied (Describe in detail):
III. CITYAGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Indhridual/Title i B) Any Financial, Familial or Professional Relationship
HPB, BOA, Planning Board, City Commies
1V. Ul~t,LVJUKtVtICKM~AIVUAMVUlY1~UtLUlftfTl,It,VMI~CIV~Al1VIV(Ul,~;LV~CWI'1C117tK/'JUUKLI~
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) $ 150.00
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 150.00
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 X No: Are you lobbying on a cresent or vending 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":
^Yes X No: Are you lobbying on a vending avDlication for a Development Agreement with the Citv or
Application for change of zoning may designation or change to the Citv's Future Land Use
Mau?
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 snot-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 X No: Are you representing anot-for-profit corporation or entity without special comvensation
or reimbursement. .
V. 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 EXPEN~Aj~~:~S--COMPENSATION DURING THE
REPORTING PERIOD. /~ ~ ~
Signature of'l:obbyist
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:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
Q ~°S
~ ~ M N o1/II. SIGNATURE AND STAMP OF NOTARY:
w V A N o0
~ L1 _ Mate of Florida, County of Miami-Dade
~~ ~ ~ 0.Sworn to nd subscrib d before me
-. ~ .o ~ ~fhis ~~ day of 20~~
,~ N N_.~.
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_W ~~
w Signature of Public otary -State of Florida
.Notarization of Lobbyist's signature
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PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 20_
Signature of Public Notary -State of Florida
Notarization of Principal's signature
.~: FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\LObbyist\LOBBYIST FORM OS.doc
Entered By:
Revised 12/08/04
ar. uasa.~vwrce yr ~ ercrN~ anu Ar~vurv i a ~r wesesraa ~ t,vr~rrnsw i avn tuax.wx wnt ~ ntK rwurce ~,
FLAT RATE OR OTHERj.
A) LOBBYIST DISCLOSURE: {Required) S 150 00
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). S 150.00
The following information must be answered:
i) Pursuant to Miami Beach Gty Code Section 2-485 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
n vac Y Nee sra you tobbr.~g~g_uresent or oendina bid for goods, eauioment or services, or on a
anent or uendina award for goods" eouiument or service?
2) Pursuant to Miami Beach Gty Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues°:
~Y~ X No• Are you 1 ing on a Wending auolication far a DeYelooment Aareeme~rt with the Ciiv or
aoolication for change of zoning man,~jgnation or chance to the Citv's Future Land Use
Ma°?
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 2481 above) who only appears as a representative of anot-for-profd
corporation or entity without special compensation of reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to arty item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees..
V. SIGNATURE UN[>ER 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
SHALT. BE FILED EVEN IF THERE HAVE BEEN NO EXP'EN COMPENSATION DURING THE
REPORTING PERIOD. ~~i f
Signatwe
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
requiremerrts. ~/
Signature of Lobbyist:
Signature of Prinapal/Giant: ~ <
VI. LOBBYIST IDENTIFICATION:
Produced ID
Form of Identification
Personally known (Lobbyist)
*~ °
~ ~ r+ N ~~/II. SIGNATURE AND STAMP OF NOTARY:
CJ ~ c~i ne
ca `~ Mate of Fkxida, County of Miami-Dade
~ ~ ~ `Sworn to ndnd wbstri before me
"" ~-° .~ "This ~~~~. - -day of 20Q~'
'~ ~~r
_ ~ v ;; F Signature of Public ry -State of Fkxida
e7. =Notarization ~ Lobbyist's signature
~~
PRINQPAI I~NTIFIGTION:
~roduced ID ,~ L_~~. ~ ~~ iJ . L
Forth of Identification
\~.eersonally known (Principal)
State of ~orida, County of Miami-Dade
Swan subsai before me
This o~ y of ~ 20
i is N - State~i~n fltS
S gnature of Publ otary
Notarization of PrindpaPs signature
=. FOR CLERK'S USE ONLY
Annual Rec~bation fee: [ j Yes j ) No Amourd Paid MCR # Date Paid
Lobbyist Registration Form received and verified by:
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Entered By:
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City of lNiami Beach, 1700 Conventiori Center Drive, Miami beach, Florida 33134, www.miamibeachfl.gav
CITY CLERK Office CityClerk@miamibeachfi.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ `~~' 1 ` t V `v` v' ~ ~' 1
I understand that no later than October 1st of each year, I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1 ~ Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
6 '~y-v~
Signature: Date:
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EXHIBIT B
DISCLOSURE OF INTEREST
Plaza Hatel, LLC
1691 Michigan Avenue, Suite 320
Miami Beach, FL 33139
MCM Miami, LLC
50% owner of Plaza I-iotel, LL,C
Sole Managing Member: Krzysztof Karbowski
NAME OF INTEREST HOLDER % INTEREST
1. Krzysztof I{ar~bowski 100.00
1691 Michigan Avenue, Suite 320
Miami Beach, FL, 33139
TOTAL FOR MCM MIAMI, LLC 100.00
Ocean Drive, Inc.
SO% owner of Plaza 1-lotel, LLC
President: lakub Kosiba
NAME OF INTEREST HOLDER % INTEREST
1. .lakub Kosiba 50.00
1811 West North Avenue Suite 401 B
Chicago, 1L, 60622
2.. Christine Kosiba 50.00
1811 West North Avenue Suite 401 B
Chicago, IL 60622
TOTAL FOR MCM MIAMI, LI,C 100.00