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Louis Taic (2)m A~'A;^s.IBEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM l ~l ~ ~~et~.-~-c.. ~. rc~~ ~~„~l ~t ~'<,~, ,~ ~ ..~ r 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 bond 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. Taic Louis NAME OF LOBBYIST: (Last) (First) (M.I.) c/o South Beach Resort Development, LLC 420 Lincoln Road, Suite 357 Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 672-4554 (305) 672-4553 Itaic@aol.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST DETAINED BY: South Beach Resort Development, LLC NAME OF PRINCIPAUCLIENT: South Beach Resort Development, LLC 420 Lincoln Road, Suite 357 Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 672-4554 (305) 672-4553 gene@southbeachrd.com 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: Louis Taic IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See attached. SPECIFIC LOBBY ISSUE: Application for Conditional Use Permit for Neighborhood Impact Establishment at 1458 Ocean Drive (a/k/a 1437 Collins Avenue), Miami Beach, Florida 33139. Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2-482(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship City of Miami Beach Planning Board None City of Miami Beach Planning Staff None ? :J i :? .:,° ~ ~ . `~'~ ` :' ° ^% ~~ -~ •" City of Miami Beach Mayor/Commissioners None City of Miami Beach Land Use & Development None L ~ ;tj ~~~ ~ ~ ~~~ 6~Q~ Committee City of Miami Beach Committees None ; .. ~ ; /` IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): LOBBYIST DISCLOSURE: (Required) Manager of So. Beach Hotel, LLC. No additional compensation for lobbying. B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Manager of So. Beach Hotel, LLC. No additional compensation for lobbying. 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 6a No: 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": ^Yes 6a No: Are you lobbvinq on a pending application for a Development Agreement with the City or application for chance of zoning map 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 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 ®No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON OCTOBER 15t OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING C NDAR EAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR C PENSATION DURING THE REPORTING PERIOD. ~ I do solemnly swear that all of the fo provisions contained in Section 2-482 Signature of Lobbyist: Signature of Principal/Client: ~ 'Signature of bbyist -Louis Taic facts are true and correc a d that I have read or am familiar with the liami ach .Code and all reporting requirements. Louis Taic, as Ma'fiager of So. Beach Hotel, LLC, on behalf of and as Managing Member of South Beach Resort Development, LLC VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID ,1 Form of Identification `~J Personally known (Lobbyist) ^ Produced ID Form of Identification Personally known (Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of - State of Florida, County of Mia ` - Sworn o and ub ibed b org,Pr~~,,• MARIA V. ERRICKSO o and subscr'be~ efor r~~"°' da ~~ / , 200 This da f ~ (~ ;~~ Notary Public -State of Fl~r~ Y \• .„ • ' : •My Commission Expires Apr t0, =" =.~` ~~'.~ Commission # DD 5260 %;FOF~ Sign r ublic Notary Statly~ol•FIo6i~led By National Notary~lf}fla r of Public Notary - St Notarization of Lobbyist's s n e ation of Principal's signature MARIA V. ERRIGKSON Notary Public -State of Florida Ay Commission Expires Apr 10, 2010 Commission # DD 526009 Bonded By National Notary Assn. TO BE COMPLETED BY CITY CLERK'S USE ON Y Annual Registration fee: [ Yes [ ] No Amount Paid $ R # $ Date Paid Lobbyist Registration Form received and verified by: r F:\CLER\LOBBYIS71Lobbyist Registration Form 32708.doc Revised 03/27/2008 m ~/itAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.pov CITY CLERK office CityClerk miamibeachfl.gov Tel: 305.673.7411, Fax: 305.673.7254 LOBBYIST NAME: Louis Taic 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 for lobbyist withdrawal in writing. / - ~~- ~ ignature: Louis Taic Date: CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* SOUTH BEACH RESORT DEVELOPMENT, LLC, a Florida Limited Liability Company LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE SO. BEACH HOTEL, LLC 58 East 79th Street New York, New York 10075 Managing Member OF MEMBERSHIP INTEREST 66 2/3% GENE GRABARNICK & PAULINE GRABARNICK, HIS WIFE, AS TENANTS BY THE ENTIRETY 6480 Allison Island Miami Beach, Florida 33141 Members GARETT GRABARNICK 5700 Collins Avenue, No. 5L Miami Beach, Florida 33140 Member 25% 8 1 /3% IF THERE ARE ADDITIONAL CORPORATIONS, UST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. Last page must be signed and notarized Page A-5(1) CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. LIMITED LIABILITY COMPANY If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* SO. BEACH HOTEL LLC a Delaware Limited Liability Company LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE % OF MEMBERSHIP INTEREST TRUST F/B/O THE CHILDREN OF CHANTAL 50% AND LOUIS TAIC U/A DATED APRIL 2, 1998 58 East 79th Street New York, New York 10075 Member OCEANFRONT EQUITIES CORP. 50% 58 East 79th Street New York, New York 10075 Member LOUIS TAIC 0% 58 East 79th Street New York, New York 10075 Manager IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE, Last page must be signed and notarized Page A-5(2) CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of an application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* OCEANFRONT EQUITIES CORP., a Delaware Corporation LIMITED LIABILITY COMPANY NAME NAME, ADDRESS, AND OFFICE % OF STOCK LOUIS TAIC 58 East 79th Street New York, New York 10075 President and Secretary 100% lF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP, NAME(S) AND EACH INDIVIDUAL'S NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE. Last page must be signed and notarized A-5(3) CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 2. TRUSTEE If the property which is the subject of an application is owned or leased by a TRUSTEE, list the beneficiaries of the trust and the percentage of interest held by each. Where the beneficiaries/beneficiary consist of corporation(s), another trust(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity.* TRUST F/B/O THE CHILDREN OF CHANTAL AND LOUIS TAIC U/A DATED APRIL 2, 1998 TRUST NAME NAME, ADDRESS, AND OFFICE JASON TAIC 58 East 79th Street New York, New York 10075 Beneficiary ALEXANDER TAIC 58 East 79th Street New York, New York 10075 Beneficiary STEFANIA TAIC 58 East 79th Street New York, New York 10075 Beneficiary LOUIS TAIC 58 East 79th Street New York, New York 10075 Trustee OF INTEREST 1/3 1/3 1/3 0% 3. PARTNERSHIP/LIMITED PARTNERSHIP If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHIP, fist the principals of the partnership, including general and limited partners. Where the partner(s) consist of other partnership(s), corporation(s), trust(s) or other similar entity, further disclosure shall be required which discloses the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity* NOT APPLICABLE PARTNERSHIP or LIMITED PARTNERSHIP NAME, ADDRESS, AND OFFICE % OF STOCK N/A N/A Last page must be signed and notarized A-6