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Allan Shulman - Isaac Urztein eti MIAMIBEACH City of Miami Beach Office of the City Clerk e.1 1700 Convention Center Drive, Miami Beach, FL 33139 c' 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. Shulman Allan NAME OF LOBBYIST: (Last) (First) (M.I) Shulman & Associates 100 NE 38 Street Miami Florida 33137 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 438 -0609 C305) 438 -0170 allan ©shulmanarchitect.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Isaac Ursztein NAME OF PRINCIPAL /CLIENT: Roshtov 909, LLC 2875 NE 191 Street Aventura Florida 33180 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 338 -1774 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: Roshtov 909, LLC - 909 Collins Avenue Property 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 H P6 eo>e- ,t/ ) / U 301 a 30 SMI? I:? A110 ' 1I hh :1 Wd L- Nnf * Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members ej rro Iggb=.J ird_qfs�d2 u f133public hearing setting. l.3 / � �i a C7 i ' ' IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) $ .00 per hour B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). .00 per 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 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 X No: Are you lobbying on a pending application for a Development Agreement with the City or application for change 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 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.. Yes X No: Are you representing a not - for - profit corporation or entity without special compensation 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 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 /Client: r VI. LOBBYIST IDENTIFICATION: -- PRINCIPAL IDENTIFICATION: Produced ID ' Produced ID 3 0 3 2 o / 7700/ For •f Identificatiorie N. Tr a Form of Identification AA 28m. Personally known (Lobbyist) U a ° Personally known (Principal) CI a VII. SIGNATURE AND STAMP OF NOTA * 8 H CO 0 State of Florida, County of Miami -Dade .n State of Florida, County of Mia -... - Sworn to a . subscribed before me a E .' °�'•. Sworn and subscribed before m• of a, , LUIS F. PINEROS This .ay o _ 4 ' , 20 I r x This L day o�. e. ,. ,� *� c Notary Public - State 01 florid °' , 1 V' r F =N + iisi � My Comm. Expires Jan 13, 20t a ‘ Commission # DD 851351 L F i AO 0 Signature of Public otary — State of Florida z !!p/lN 2 SignatureW7 blic l otary — St. - _ • .. Notarization of bbyist's signature Notarization of P incipal's signature FOR CLERK'S USE ONLY X¶ V7 > Annual Registration fee: [ ] Yes [ ] No Amount Paid ?.7 — MCR # 4 , e Paid II Lobbyist Registration Form received and verified by: , Enter-, By: F: \CLER \$ALL \MARIA -M \ Lobbyist \LOBBYIST FORM 05.doc 147/41 �� ` Revised 12/08/04 MI City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: -t411(01 Sh. u' 1 / l ‘` I understand that no later than October ll st 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. S 43/1 Signature: Date: F:ICLERILOBBYISTILobbyist Registration Form 32708.doc