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Alexander I. Tachmes - Shore Clubt/\ i A/v\ 1 AC 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 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 excl ions. Please refer to Ordinance 2004 -3435, NAME OF L BBYIST: (Last) (First) (M.I) s k- -7 2� \ S , 9 W�.fl Y �� q L.- V D s.ckET \S � w&t BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) f L- 3 3 l� / ,5 6 5 Ui� -73 I - c �� Li ' -'-7'-i scf 6',s- TELEPHONE NUMBER: FAX NUMBER: EMAIL :a `v Please notify this office if your contact information changes: address, phone, or a -rnai/ address. 1. LOBBYIST RETAINED BY: -S 3 e— ) ? _ck_4, Niet �.- Cab NAME OF PRINCIPAL/CLIENT: 973,1\—�AEID .D E s 0 TELEPHONE NUMBER: (Number and Street) (City) (State) (Zip Code) 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: n.SP.ECIFI.C;:LOB.BY'I.SSUE: nrS-Q<I1/4-- Issue to be lobbied (Describe in detail):) III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: 1 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 cit to the resent date, statin the eneral nature of the subject contractual relationship. Sec 2-482(a)(4) Full Name of title of erson to be lobbied v ■ ,,i Contractual Relationship (Explain) YES NO Li �' t/ ,. -(;-ez. 5 �k r 0_� -) 4`--s. 1 `wt1 �. t Pursuant to City Cole Section 82(g) Every registrant shall be required to state the extent of any business, financial, tamihal or professional relationship, or other relationship giving rise to an appearance of an impropriety, with alrsyic�rrenta ity)coymmissione ^or city personnel who is sought to be lobbied as identified on the Lobbyist registration form filed. '-• • i , Ill , Sec 2- 482(g) An Financial, Familial or Professional Relationshi• v ■ ,,i 11 JddlVZig/ F: \CLER \$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) -*:25-1)(1 C- B) PRINCIPALS DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). v /� The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2 -488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement I - es ": € Yes ► Are ou lobb in on a •resent or •endin bid for •oods equipment or services or on a •resent or •endin 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 (€ t : 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 riot-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 €Nla: 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-BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Q--3*** Signature o'rtl'bbyist I do solemnly swear that all of the foregoing facts are true d correct and that I have read or am familiar with the provisions contained in Section 2 -482 of the Miami each City Code and 111 repo ng requirements. Signature of Lobbyist: J Signature of Principal /Client: VI. LOBBYIST IDENTIFICATION: Produced ID /'Z .✓e.QS Lic. • Form of Identification € Personally known (Lobbyist) VII. SIGNATURE AND STAMP 0 State of Florida, County of Miami -Dade Sworn to and subscribed •e . e. e This D •ay of !I'�f 2011 • Signatur Notarizati ei Pty '% ISABEL SATCHELL MY COMMISSION # DD 879891 �•, • �4,. EXPIRES: April 13, 2013 Bonded TO.; Notary P ,Iic Un rwriter Public Notary — State of Florida n of Lobbyist's signature PRINCIPAL IDENTIFICATION: Produced ID FL J2jr✓e.deS tic Form of Identification € Personally known (Principal) ISABELSATCHELL MY COMMISSION # DD 879891 EXPIRES: April 13, 2013 ' Bonded Thru Notary Public Underwriters State of Florida, County of Miami - a Sworn and subscrib-d efor;e me Th' day _ I / , 2011 Signat _ 'f Public Nota — State of Florida Notarizati n of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ] Yes [ ] No Amount Paid $ Lobbyist Registration Form received and verified by: MCR # Date id F: \CLER \$ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc = orm.doc Revised 1 /11 /2D11 /\/\ 1 /\1f'�% g City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florido 33139, www.miamibeochfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel: 305.673.741 1 , Fax: 305.673.7254 LOBBYIST NAME: 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. Pursuant to Section 2 -485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to timely file a Statement and in addition to any other penalties which may be imposed as provided in Section 2- 485.1, a fine of $50.00 a day shall be assessed for all Statement(s) filed after the due date. The City Clerk shall notify the Miami -Dade County Commission on Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the assessed fines after notification. Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami -Dade County Commission on Ethics and Public Trust. (9J---c)-A Signature: F: \CLER\$ALL \aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc 2,, Date: DISCLOSURE OF INTERESTS The Shore Club, located at 1901 Collins Avenue, Miami Beach, Florida, is owned by Philips South Beach, LLC, which in turn is owned as follows: I. Ninety -three and twenty -one hundredths percent (93.21 %) of Philips South Beach LLC is owned as follows: 1.00% SB Realty Corp., which in turn is owned as follows: 90.00% Philip Pilevsky 417. Fifth Avenue New York, NY 10016 10.00% Sheila Levine 417 Fifth Avenue New York, NY 10016 36.04% Philips SB Associates, LLC, which in turn is owned as follows: 90.00% Philip Pilevsky 41.7 Fifth Avenue New York, NY 10016 10.00% . Sheila Levine 417 Fifth Avenue New York, .NY 10016 56.17% Clark SB II, LLC, which in turn is owned as follows: 3.32% Jonathan A. Bernstein 993 Park Avenue New York, NY 10028 96.68% Clark SB, LLC, which in turn is owned as follows: 32.05% The Clark Foundation One Rockefeller Plaza New York, NY 10020 -2102 (this is a 501(c)(3) charitable foundation) Directors/Members: Kent L. Barwick Felicia H. Blum • • Jane Forbes Clark William M. Evarts, Jr. Gates Helms Hawn Archie F. MacAllaster Joan S. McMenamin Kevin S. Moore Thomas Q. Morris Anne L. Peretz Edward W. Stack John Hoyt Stookey Alexander F. Treadwell Clifton R. Wharton, Jr. 25.64% James F. Clark c/o The Clark Estates, Inc. One Rockefeller Plaza New York, NY 10020 -2102 15.38% The Scriven Foundation One Rockefeller Plaza New York, NY 10020 -2102 (this is a 501(cX3) charitable foundation) Directors/Members Robert G. Campbell, M.D. Jane Forbes Clark Edward Gozigian J. Michael Moffat Kevin. S. Moore Thomas Q. Morris, M.D. Marian G. Mullet Edward W. Stack 7305% Trust for Anne Peretz, 1944 c/o The Clark Estates; Inc. One Rockefeller Plaza New York, NY 10020 -2102 Income beneficiary: Anne Peretz es • Residuary beneficiaries in equal amounts: Jesse Peretz Evgenia Peretz David Farnsworth Anne E. Farnsworth (addresses for each are set forth below) 3.21% Trust for Martin Peretz, 1976 c/o The Clark Estates, Inc. One Rockefeller Plaza New York, NY 10020 -2102 1.28% Income beneficiary: Martin Peretz Residuary beneficiaries are: 50% in equal amounts to: Jesse Peretz Evgenia Peretz David Farnsworth Anne E. Farnsworth (Addresses below) 50% To charities to be designated David L. Farnsworth 9 Brantwood Road Arlington, MA 02476 1.28% Anne E. Farnsworth 4001 Virgilia Street Chevy Chase, MD 20815 L28% Jesse W. Peretz 533 Canal Street Unit 3 New York, NY 10013 1.28% . Evgenia Peretz 171 Duane Street No. 2 5.13% • New York, NY 10013 Edmund S. Twining III P. 0. Box 8 Driggs, Idaho 83422 3.85% Eve C. Labouisse 1 Sutton Place South New York, NY 10022 1.03% Edward W. Stack 25 Waverly Street Glen Head, NY 11545 0.515% Kevin S. Moore 79 Norfield Road Weston, CT 06883 0.51% Richard C. Clarkson 24 Roxbury Road Garden City, NY 11530 0.515% Anne B. Moore 418 East 59th Street #24A New York, NY 10022 Ih The remaining six and seventy -nine hundredths percent (6.79%) of Philips South Beach, LLC is owned as follows: 100% Hotel Parent LLC, which in turn is owned as follows: 80.38% NorthStar Hospitality LLC, which in turn is owned as follows: 100% NorthStar Partnership L.P. which is in turn owned as follows: 73.34% NorthStar Capital Investment Corp. 527 Madison Avenue, 16th Floor New York, NY 10022, which in turn is owned as set forth on Exhibits "A" and "B" attached hereto • 9.44% Sorco Interfund LLC Sorco Fund Management 888 7" Avenue New York, NY 10022 8.43% NorthStar Operating LLC, which in turn is owned as follows: 48.58% David Hamamoto 527 Madison Ave 16"' Floor New York, NY 10022 ' 48.58% W. Edward Scheetz 527 Madison Ave 16th Floor New York, NY 10022 1.58% David G. King Jr. 527 Madison Ave 16"' Floor New York, NY 10022 0.36% Peter W. Ahl 527 Madison Ave 16' Floor New York, NY 10022 ,0.22% Marty Lamb. 527 Madison Ave 16' Floor New York, NY 10022 012% Keith Meister 527 Madison Ave 16th Floor New York, NY 10022 0.08% Greg Peck • 527 Madison Ave 16"' Floor New York NY 10022 • 0.11% 0.11% Adam Anhang 527 Madison Ave 16th Floor New York, NY 10022 Charlie Humber 527 Madison Ave 16'b Floor New York, NY 10022 0.08% Harriet Z. Stamatakos • 527 Madison Ave 16th Floor New York, NY 10022 0.06% Glenn Levin 527 Madison Ave 16"' Floor New York, NY 10022 0.02% Denise Olsen 527 Madison Ave 16th Floor New York, NY 10022 4.83% NorthStar Capital Partners LLC, which in turn is owned as follows: 50% David Hamamoto 527 Madison Ave 16"' Floor New York, NY 10022 50% W. Edward Scheetz 527 Madison Ave 16t Floor New York, NY 10022 2.25% DB Alex Brown Exchange Fund II L.P. DC Investment Partners 10 Burton Hills, Suite 120 Nashville, TN 37125 • 0.88% DB Alex Brown Exchange Fund I L.P. DC Investment Partners 10 Burton Hills, Suite 120 Nashville, TN 37125 0.33% David G. King Jr. 527 Madison Avenue, 16th Floor New York, NY 10022 0.29% Marc S. Gordon 527 Madison Avenue, 16th Floor New York, NY 10022 0.10% Richard J. McCready 527 Madison Avenue, 16t Floor New York, NY 10022 0:08% Peter W. Ahl 527 Madison Avenue, 16t Floor New York, NY 10022 0.02% Richard Sabena 527 Madison Avenue, 16th Floor New York, NY 10022 0.01% . Kevin Reardon 527 Madison Avenue, 16t Floor New York, NY 10022 19.53% RSA Associates, L.P., which in turn is owned by the Ian Schrager family entities listed below, as follows: 0.781609% RSA GP Corp. (General Partner) 47510' Avenue New York, NY 10019 • 7679319% Ian Schrager (Limited Partner) 475 10"` Avenue New York, NY 10019 11.400956% RSA New York Associates, LP (Limited • Partner) 475 10th Avenue New York, NY 10019 0.238116% RSA New York Corp. (Limited Partner) 475 10"' Avenue New York, NY 10019 65.00% RSA Family Holdings, LLC (Limited Partner) Managing Member: Ian Schrager Non - Managing Schrager Family 1999 Trusts UTA dated August 29, 1999, Trustees: Ian Schrager and Rita Schrager, 475 10th Avenue New York, NY 10019 15.00% ISB Family Holdings, LLC (Limited Partner) Managing Member: Ian Schrager Non - Managing: Schrager Family Spray Trust UTA dated Sept. 29, 1999 Trustees:Bemard Schrager And Stuart Kotler 475 10th Avenue New York, NY 10019 0.09% By the following Philip Pilevsky entity: Century Operating Associates 475 10th Avenue New York, NY 10019 CD YPi a. at M9 •a• W O M. 111 tat n d S R• w gC 14 CC W n 14 Z low �rJq 1111.4 %WV J 111.4 LOH 10/20'4 01Z -1 12~11.2212+ A • i a O D +" a. 0 N. Egg n" PAM NNW ow AA A W°. OSP-% MOWN xOSSxs xs C -W 14 auVI 1-aof : ab,EO a 0 et ot Dt N O OC' wR G 1. V • • • a w j 114 0 0 0 1� A' 0 11; 14.1 to 4 1e M 4 1• 19' • O • • .. P 1. 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