Suria Yaffar BH 4000 Alton, LLC MIAMI BEACH �00
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 exclusions. Please refer to Ordinance 2004-3435.
Yanr Suria
NAME OF LOBBYIST: (Last) (First) (M.l)
Zyscovich, Inc. 100 North Biscayne Blvd., 27th Floor, Miami FL 33132
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 372-5222
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
BH 4000 Alton. LLC
NAME OF PRINCIPAUCLIENT:
Same 2711 South Ocean Drive, Suite 2404, Hollywood, FL 33019
1 'TNE�'S'RTl01t 5'S (Number and 5 ree 5 Sae (Zip Code)
(954)416-3140
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2482(c))
NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: Dan Lebensohn,President of CLR Realty South,Inc.,the Manager of BH3 400
Alton,LLC,the Manager of BH 4000 Alton,LLC
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
Code amendment, land use amendment, rezoning application, development approvals & permitting issues for
redevelopment of the property located at 4000 Alton Road
Issue to be lobbied(Describe in detail):
Ill. CITY AGENCIEWINDIVIDUALS TO BE LOBBIED:
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
arson's commencement of service with the city to the present date,st ting the general nature of the subject contractual relationshi .
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES I NO
title of person to be lobbied
Staff of Planning Department, Building Department,and Public Works None X
Department
PB, HPB,BOA,City Commission,as necessary None X
Pursuant to City Code Section 2-482(8)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 urgent city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482 Any Financial, Familial or Professional Relationship f Mpg
None
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATIO 3
4d
(REQUIRED). $ U✓
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,eauioment or services.or on a present or pending
award for goods.eauioment 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 lobbying on a pending application for a Development Agreement with the City or application for
change of zoning mao designation or change to the City's Future Land Use Mao?
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
Ma THE PRECEDING CALENDAR YEAR, A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR
r o b
I do solemnly swear that all of the foregoing facts are true and cor ct and that I have read or am familiar with the provisions contained
in Section 2-482 of the mi Beach City Code and all reporting requirements.
Signature of Lobbyi t: I ,�L _ J ,,wl ._ \
Signature of Principal/Client: Van (-xb mS t Q44� S x re 1
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: J
_Produced ID _Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) _Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, Count of Miami-Dade to of Florida, County of Miami-Dade
Y `•;Pay��a'• JANAINA ESTANISLAU
Sworn to and subscribecl before me :z orn and subscribed before me
Th' '� day of � , 2013 _ W - Notary Public-State of Florid
y My Comm.Expires pct 29,2011 s day of , 2013
;;oF«a�` Commission'#EE 847409 NlLal
ture of Pu is Notary—State of Flori a Signature o Public Notary—State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
I/Yes BE COMPLETED BY CITY CLERK'S STAFF ONLY G�
Annual Registration fee: �"/// Yes No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by-
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) $ A
Z�Sb.GAD
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPEISAT01 f:/
(REQUIRED). $ Z. O�Gam/ n
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,eauinment or services,or on a present or pending
award for aoods.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 Dendina application for a Development Agreement with the City or application for
chanae of zonina mat)desianation 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 representina 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
EM 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:
'40 40
e i.
_Produced ID _Produced ID
Form of Identification Form of Identificatio
x�CD
_Personally known(Lobbyist) JZPersonally known(Principal) a G r
3 y
mN of g
VII. SIGNATURE AND STAMP OF NOTARY: N N
om m
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade m io
N
Sworn to and subscribed before me Swor nd scribed before me w o
This day of 2013 This y of 1 2013 J
Signature of Public Notary—State of Florida Sig ature ublic Not —State of Florida
Notarization of Lobbyist's signature No ization PrinciDaI's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: Yes No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by:
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F:\CLE istration Form.doc Revised 04/27/2012
NAIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.inianiibeachf.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachtl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: Suria Yaffar
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 $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.
Slgn ly e: I Date:
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