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Michael W. Larkin - Jonathan & Karen Sepsenwol E 3 /i0 62rce, hiSPH- 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 principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or derision 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. Larkin Michael W. NAME OF LOBBYIST: (Last) (First) (M.I) Bercow, Radell & Fernandez, P.A. 200 S. Biscayne Blvd., Suite 850 Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 377.4231 (305) 377 -6222 mlarkin@brzoninglaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Jonathan and Karen Sepsenwol NAME OF PRINCIPAL /CLIENT: 6335 LaGorce Drive Miami Beach Florida 33140 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 788 -2385 Jonathan.Set senwol©gpavnet.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: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: C-) o Proposed Addition to Single family Home located at 6335 LaGorce Drive, Miami Beach, Florida a;' Issue to be lobbied (Describe in detail): III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: rT- N A) Full Name of Individual /Title -0 < B) Any Financial, Familial or Professional RetatiorLship 1-1 None CP * Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not lobbied outside of a public hearing setting. 11/22i2011 X9:55 305377522 BERCOW RADELL PAC E 02/05 . 64' AA I ANAL BEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbylsl; means all persons employed or retained, whether Paid or not, by a principal who seeks to encnuraae me or modification of any ordinance, resolution, action or deosion of any commissioner; any action, decision, recommendat on oe d ie ON 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 races on such action, decision or recommendation that foreseeably will be her or revie..ved by the dty commission, or a city board or committee, The term specifically Includes the principal as well as any ernplotyee erpaQee in lobbying activities, The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004 -3435, Larkin Michael NAME OF LOBBYIST' (Last) (First) 1 Bercow, Radeil ii Fernandez, P.A. 200 S Biscayne Blvd., Suite 850 BUSINESS NAME AND ADDRESS Miami S t) Ji ;. (Number and Street) (City) t----- 00511 (321131 TELEPHONE NUMBER: FAX NUMBER: mtzr5 puLzen rlAlu rn-, EMAIL: I. LOBBYIST RETAINED BY: Jonathan and Karen Sepsenwroi NAME OF PRINCIPAL/CLIENT. f ?S L GorCP, Drive Miarn, B? BUSINESS NAME AND ADDRESS (Number and Sir t) (Ci ach Florida " (State) (zip Ccdej (30S) 788 -2385 TELEPHONE NUMBER; Jonathilc_Se eT a �vL' .sID PAY NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)3 • NAME OF CHIEF OPFICER, PARTNER, OR. GENE ICIARY ' • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A E4 OR MORE OWNERSHIP INTEREST IN SUCH ODRPORATION, PARTNERSHIP OR TRUST: 1 II. SPECIFIC LOBBY ISSUE: _1 Proposed Addibor. to Single family Home located at 6335 LaGorce Drive, Mimi Beach. Florida Issue :o be lobbied (Describe in detail): III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: :: * A) Full Name of Indhridual /Title — { B) Any Financial, Familial or Professional Relation.5l'i�o I rte._) TI tin 1 1 F I hi 1 None ,. � . 1! I'�1('1( V�cv.1 ; -4 A / I} _ ��, �. , .1 fi Unle ar -.QC is ic legative in nature, g, BOA, Plarn,r Board, and City Commission members. Are no lobb■ecl ourr1de oft public heannc EeRi i i • .. ' IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): 4 1°3 A) LOBBYIST DISCLOSURE: (Required) $ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ 43s, (i v The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2 -488 Entitled "Prohibited Campaign Contributions By Lobbyists 1 On Procurement Issues ": f.7 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 Lob.yist 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 Cede and all reporting requirements. V\*/ Signature of Lobbyist: l Signature of Principal /Client: �1 , 1 AI "---- -� VI. LOBBYIST IDENTIFICATI■ N: PRINCIPAL IDENTIFICATION: [] Produced ID ` .i Produced ID Form of Identification Form of Identification ca o 4 Y Personally known (Lobbyist) u_ N je!�Personafly known (Principal) """4� Public w Notary Puc Stab N Florida ° v, • I. SIGNATURE AND STAMP OF NOTARY: `F Mara Hernandez in o u N ` MY Commission EE0o616i .g E .Na V. or or Expires Oa/05/2015 v a Ir s o • .te of Florida, County of Miami -Dade State of Florida, County of Miami -D.. orn to And subscrib f re e s Sworn d subscrib-d befor_ e a. 2 . m f a • is : p • - o 10 I2e 2011 This day of i . ,,,Q' 2 e ' :fill 11111 3J � . y it 'nature of Public Notary — State of Florida Signature * at of F .rida • I <r Si nature of Public No. 1- •g ` •tarization of Lobbyist's signature Notarization of Principal's si.! :tu e I OM , .„::- FOR CLERK'S USE ONLY Annual Registration fee: [ j Yes o Amount Paid T MCR # Date Paid if��/ Sei Lobbyist Registration Form receiv d and verified by: '. i .: 1 /,a, Entered By: e ifii-it_L F: \CLER \$ALL \MARIA•M \Lobbyist \LOBBYIST form 05.doc - e i sed 1 08/04 City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochf(gov CITY CLERK Office CityClerk @miomibeachfl.gov Tel: 305.673.741 1 , Fax: 305.673.7254 LOBBYIST NAME: MICHAEL W. LARKIN 1 understand that no later than February 28th of each year, 1 must file the following form, 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 and Compensation 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. (//1A, C/.34 Signature: Date: