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Wayne M. Pathman - Palau Sunset Harbor, LLCCity 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 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. Pathman Wayne M. NAME OF LOBBYIST: (Last) (First) (M.I) Pathman Lewis, LLP, One Biscayne Tower, Suite 2400, 2 S Biscayne Blvd, Miami, FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) ) (City) (State) (Zip Code) 305 - 379 -2425 305 - 379 -2420 wpathman @pathmanlewis.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes: address, phone, or e-mail address. LOBBYIST RETAINED BY: Palau Sunset Harbor, LLC NAME OF PRINCIPAL/CLIENT: Meir Srebernik, c/o Mathew Cicero, South Florida Condominium Management, Inc., 3100 NW BUSINESS NAME AND ADDRESS (Number and Street) (City) 305 - 634 -7607 305 - 637 -3699 TELEPHONE NUMBER: FAX NUMBER: (Optional) 72 Avenue, Suite 113, Miami, FL 33122 (State) (Zip Code) mcicerot7a sflamgt.com 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: Meir Srebernik, President, Palau Sunset Harbor, L • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See Attached Exhibit "A" LC u.SPECIFIC LOBBY ISSUE: Develop property with a mixed -use residential and commercial structure (requiring conditional use permit Issue to be lobbied (Describe in detail): Jtt / 015- /�2 //r/PV/ �t g 3 /31 0,20 XS/T66r ill. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: /r Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's commencement of service with the city to the present date, stating the general nature of the subject contractual relationship Sec 2- 482(a)(4) Full Name of Individual and title of person to be lobbied Contractual Relationship (Explain) YES NO Planning Board, Design Review Board X Richard Lorber, Acting Planning & Zoning Director X City Planners - Mercy Lamazares, Michael Belush, Katia Hirsh X Pursuant to -- iy Code Section 2- 482(g) Every registrant shall be required to state the extent of any bdsine`ss;,Jfin�r%cjal; fa ilia) rofessional relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city' pe jonnel who is sought to be lobbied as identified on the lobbyist registration form filed. 1 Sec 2- 482(g) Any Financial, Familial or Professional Relationship " i None IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) Hourly - $400.00 B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): Hourly - $400.00 (Required). 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 n 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 Ri 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 1 No: Are you representing a not - for - profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON FEBRUARY 28th 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 B ILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyis I do solemnly swear that all of the foregoing facts are true and corr -cf and that I have read or am familiar with the provisions contained in Section 2 -482 of the Miami - - _..e__.. Code and all reporting requirements. Signature of Lobbyist: Signature of Principal /CI VI. LOBBYIST IDENTIFICATION: ❑ Produced ID Form of Identification 0 Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami -Dade Sworn to and subscribe. a -fore me This `' i� i .1ay o `', - , 204X 2012 nature I Pu. is No ary — - of Florida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: Produced ID Form of Identification LX Personally known (Principal) State of Florida, County of Miami -Dade Sworn •. subscrib efore me This da C.4.! 20CIX 201 nature of ° "blie 1otary —State o lorida Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ] Yes [ ] No Amount Paid $ "1250 ""' MCR # /LJ 9' Lobbyist Registration Form received and verified by: F: \CLER ..$A'_C-. =\a ° )RNIS \LOB YIS P,PiS \Lobbyist I nnual Registration ; orm.dec Date Paid ,92/1/74 i./7 lv Revised 1/11 2011 City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Wayne M. Pathman CityClerk @miamibeachfl.gov I understand that no later than February 28th of each year, I 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. ate: Interests in Palau Sunset Harbor, LLC Percentage of Interest Palau Sunset Harbor Investors, LLC 80% Attn: Stanley P. Gold c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive Burbank, CA 91505 Palau Sunset Harbor Management, LLC Attn: Stanley P. Gold c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive Burbank, CA 91505 20% Interests in Palau Sunset Harbor Investors, LLC Percentage of Interest Roy P. Disney Living Trust dated 5.545% November 30, 2001 c/o Kathleen Galli Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Gregory S. Martin 20 Birchwood Irvine, CA 92618 David K. Robbins Bingham McCutchen LLP 355 S. Grand Avenue Suite 4400 Los Angeles, CA 90071 SK Miami, LLLP Attn: Meir Srebernick 900 Biscayne Boulevard, #2802 Miami, FL 33132 91.237% 1.109% 1.109% 1.00% Interests in Roy P. Disney Living Trust Dated November 30, 2001 Percentage of Interest Roy P. Disney 100% c/o Kathleen Galli Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Interests in Shamrock Holdings of California, Inc. Percentage of Interest Patricia Disney Trust dated November 17, 2006 50% c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Estate of Roy E. Disney c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 50% Interests in Patricia Disney Trust dated November 17, 2006 Percentage of Interest Patricia Disney 100% c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Interests in the Estate of Roy E. Disney Percentage of Interest Roy P. Disney 25% c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Abigail E. Disney c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Susan Disney Lord c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 Timothy J. Disney c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 25% 25% 25% Interests in Palau Sunset Harbor Management, LLC Percentage of Interest Gold Living Trust dated February 14, 2000 25% as amended Attn: Stanley P. Gold c/o Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive Burbank, CA 91505 Gregory S. Martin Shamrock Holdings of California, Inc. 4444 W. Lakeside Drive, 3rd Floor Burbank, CA 91505 SK Miami, LLLP Attn: Meir Srebernick 900 Biscayne Boulevard, #2802 Miami, FL 33132 25% 50% Interests in Gold Living Trust dated February 14, 2000 As Amended Percentage of Interest Stanley P. Gold 50% c/o Shamrock 4444 W. Lakeside Drive Burbank, CA 91505 Ilene Gold c/o Shamrock 4444 W. Lakeside Drive Burbank, CA 91505 50% Interests in SK Miami, LLLP Percentage of Interest Meir Srebernick 70% 900 Biscayne Boulevard, #2802 Miami, FL 33132 Gil Kevitz 900 Biscayne Boulevard, #2802 Miami, FL 33132 30%