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Michael A. Gil/J. Cubed, LLCm MIAMIBEACH 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 prindpal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or decision of any commissioner, any action, derision, recommendation of the City Manager or any rity board or wmmittee; or any action, derisiai or recommendation of any rity personnel during the time period of the entire derision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the aty commission, or a rity board or committee. The term specificalty inriudes the principal as well as any employee engager! In lobbying activities. The berm "Lobbyists' has spedfic exdusions. Please refer to Ordinarroe 2004-3435. Gil Mid~ael A NAME OF LOBBYIST: (Last) (First) (M.I) Bercow, Radell B Fernandez P.A. 200 South Biscayne Blvd., Suite 850 Miami, Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 377-8690 (305) 377-6222 mgil@brzoninglaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST RETAINED BY: J Cubed, LLC NAME OF PRINCIPAL/CLiENT: 1691 Michigan Avenue Suite 320 Miami Beach FL 33139 BUSINESS NAME AND ADDRESS (Number and Street) (Gty) (State) (Zip Code) (847) 675-0005 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (c)] NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Adam Schwartz • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: vrginia Bender, Jakub Kosiba, Kryzstof Karbowski, ]grit Franco, and Adam Schwartz II. SPECIFIC LOBBY ISSUE: Redevelopment of 421 and 425 Meridian Avenue -Modification of COA and variance approvals Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUAtS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship Planning Dept., HPB, BOA, Planning Board, City Commission * None ~~0 ~~!~1 S,!~N:~l~ ~1.1~ CS ~8 W~ ~ Z 1~0 8001 * Unless an issue is legislative In nature, HPB, BOA, Planning Board, and City Commission mer~r~rtt 1„r~~:~e of a publk hearing settlng. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER /!O(/RLY FL4T RATE OR OTHERJk A) LOBBYIST DISCLOSURE: (Required) * ~~0 00 cer hour B} PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 2$ 20.00 Der 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": ^ Yes X No• Are you lobbying on a sent or vending ~gQods" eo~lioment or services, or on a present or ioendiiifo award for goods equiome~ or service? 2) Pursuant to Miami Beach Gty Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Reat Estate Development Issues": ^Yes X No• Are Tg lyl obbYi~,g on a oendina aoolication for a Development Agreement with tl~e City or aioioliication for chance of zoning map~,gnation or chance fin the City's Future Laed 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 2-481 above) who ony appears as a representative of a not-fnr-profit corporation or entity without spedal 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.. V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYLST 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 Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/C VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID ^ Produced ID Form of Ident~cation Form of Identification ~ ` ~ g "m Z W 'TI o ~ ~ e,~Personally known (Lobbyist) ^ Personally known (Principal) -o N• 'T1 ~, °oo ~~n N VII. SIGNATURE AND STAMP OF NOTARY: N N ~ a ~ ~ o ~ r. „ s ~, State of Florida, Coun of Miami-Dade State of Fbrida, County of Miami-Dade eo ~ m ~ ~ ~ n Swo and subscri ore me Swom and subscri before me ~ °. O z° Q ~ w Thi ~ day 20 l~ ~ 9r~' day ofJ~~ 20 4p = a r ; ~~. • eob ~ ~ ~' f ~ ~~ Signatu of Public otary - S of Florida Sign of Publ'~c Notary -State of Florida ~~N. ~*~" NOta ZatlOn Of byist's nature N zation of Prindpal's signature ~° FOR CLERK'5 U E ONLY g (f Annual Registration fee: [ ]Yes [ ] No Amount Paid ~ MCR # ~ ` ~ ate Paid ~r ~ Lobbyist Registration Form received and verified by: Entered By: . F:\CLER\BALL\MARIA-M\Lobbyfst\LOBBYISTIORM OS.do[ Redsed 12/06/04 ~J~ . City of Miami i3each, 17rJQ Corventio~ Center Drive, hAiami Beoclr, Florida 33139, www.rniomibeach#i.gov C1iY CLERK Office CityCEerk~m=amibeacbfl.gov Tel: 305.b73.741 1 , l:ax: 3t?S.b73.7254 ! understand that no later than i?ctober 1st of each Xec~r, I must file the following forms, pursuant to Section 2-4$5 of the Miami Beach Ci#y 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 #imely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and far code violation evaluation. !n addition, once an issue 1 have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's ©ffice of lobbyist withdrawal in writing. Signature; Date: r,;2t;,",~;