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Michael W. Larkin - David Dushey r` N�, IAMI. BEAC City of Miami Beach Office of the City Clerk 13 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. Larkin Michael W. NAME OF LOBBYIST: (Last) (First) (M.1) Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5300 (305) 377-6222 mlarkingbrzoning law.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: P/ease notify this office if your contact information changes address,phone, ore-mail address. _ I. LOBBYIST RETAINED BY: David Dushev NAME OF PRINCIPAUCLIENT: 735 Collins, LLC, a Delaware Company 275 Madison Ave., Suite 702, New York, NY 10016 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (212)889-6405 (212)889-6922 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:David Dushey • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:see attached Exhibit A II. PECIFIC_L® Y ISSUE Development Approvals for renovations to the Lynmar Hotel at 735 Collins Avenue Issue to be lobbied(Describe in detail): III., AGENCIES/INDIVIDUALS' 0 EE L® DIED: I..___�. t_._.....__,..._. em...__-. _>._ 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 Contractual Relationship(Explain) YES NO title of person to be lobbied Planning Department and Building Department Staff one X B, HPB, BOA, City Commission, as necessary* None X Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is sought to be lobbied as identified on the lobbyist registration form filed. Sec 2-482(g)Any Financial, Familial or Professional Relationship - ` 1"`t`_ -' aj A 141 b- Ija C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc r `Ti q 1 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $445 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):. (REQUIRED). $445 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 lobbvina on a present or pending bid for goods,eauipment or se rvices. or on a present or pending award for goods,eauipment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes X No: Are you lobbvina on a pending application for a Development Agreement with the City or application &change of zoning map designation or change to the City's Future Land Use Map? 3) Pursuant to Miami Beach City Code Section 2-482 (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 FEBRUARY 28 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 FQB 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: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ep �o � � N Produced ID Produced ID 3 c Form of Identification U. 4M Form of Identifcati(Z Z-*U 'S o oN c C Personally known(Lobbyist) N'0 W /Personally known(Principal) 0 2, VII. SIGNATURE AND STAMP OF NOTARY: CL tj E o _6"� x m V a WW Ita- Il�Z 0 C State of Florida, County of Miami- ade z°<2 w State of-lerk4a;County of Mieff*15=r�,Z o Sworn to subscribe_d be Vor, .,, Sworn and subscribed before me This day of ,2012 ;' °� This 1 4�day of , 2012 Z E Signatur f Public Nota —State o orida Signature of P blic Notary—State ofFlee-1Jew�a/�-- otar' tion of signatu Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFYONLY Annual Registration fee:. [ ],Yes-[ ]No Amount Paid$ MCR# Date aid Lobbyist Registration Form received and verified by: l Cq/ C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Regist ation Formrevised 5-30-2012.doc F:�CLE, istration Form.doc Revised 04/27/2012 ,M-1 A.¢ BE A(0-5.`0 !Hh City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachil.bov C'VFY CLERK Office Rafael E. Granada, City Clerk CitvClerk(, .;miamibeach(l.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Michael W. Larkin I understand that no later than February 28 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, or I am no longer lobbying on that issue or for that principal, 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 $5.0.00 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. Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Exhibit A: Corporate Disclosure 735 Collins, LLC c/o Joseph Dushet1, Jenel Management Corp., 275 Madison Ave Suite 702, New York, NY 10018 NAME, ADDRESS, AND OFFICE % OF STOCK Joseph Dushem 20% 275 Madison Ave Suite 702 New York NY 10018 David Dushey 24% 275 Madison Ave Suite 702 New York NY 10018 Sam J. Dushe_M 16% 275 Madison Ave Suite 702 New York NY 10018 Sam A. Dushey 20% 275 Madison Ave Suite 702 New York NY 10018 Blue Collins 20% 140 Fulton Street, 5th Floor New York NY 10038 Blue Collins, LLC- 140 Fulton Street, 5th Floor, New York, NY 10038 NAME, ADDRESS, AND OFFICE % OF STOCK Rammond Gindi 25% 140 Fulton Street, 5th Floor New York NY 10038 Isaac A. Gindi 25% 140 Fulton Street, 5th Floor New York NY 10038 Isaac S. Gindi 16.667916 140 Fulton Street, 5th Floor New York NY 10038 Jack Gindi 16.666% 140 Fulton Street, 5th Floor New York NY 10038 Eddie Gindi 16.667% 140 Fulton Street, 5th Floor New York NY 10038