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Kobi Karp - 14 La Gorce LLC ® MIAMI BEACH � In' AL 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. Karp Kobi NAME OF LOBBYIST: (Last) (First) (M.1) Kobi Karp Architecture& Interior Design, Inc. 2915'Biscayne Boulevard, Suite 200 Miami Florida 33137 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 573-1818 (305) 573-3766 kobikaroa-kobikaro.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or a-mail address. I. LOBBYIST RETAINED BY: 14 La Gorce LLC NAME OF PRINCIPAL/CLIENT: 90 Amelia Avenue Coral Gables Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)445-4458 (305)445-4458 tom @uniontitleservices.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: Please see attached Exhibit A. • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: ii.SPECIFIC LOBBY ISSUE: Development Approvals and Permitting Issues for 14 La Gorce LLC c ^� Issue to be lobbied(Describe in detail): 41 III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: _E Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be lobbied,and whethoi the lobbyist as entered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 fniontfV preceding such arson's commencement of service with the city to the present date,stating the general nature of the subject contractual relationslii . :=Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain), YES NO title of person to be lobbied Y; — s i► Tanning Department and Building Department Staff None - X B, DRB, 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 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 None F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc r 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 COMPENSATION): (Required). 13 The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ues €Yes Noe)Are You lobbying on a aresent or pending bid for goods.eauiament or services.or on a present or oendina award for aoods.eauiument or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": EYes No- I Arp you lobbyano on a oendina application for a Development Aareement with the City or a[)i)licat*on fo chance of zonina map designation or chanae 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. N­ A—you renresenteng a not--for-profit comorabon or entity without snecial 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 CEIVEQ. IN THE CITY OF MIAMI BEACH EM THE PRECEDING CALENDAR YEAR, A STATEMENT SHALL E'llAdI11111IFFN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD, Signature of Lo I do solemnly swear that all of the foregoing facts are tru nd correct and that I have re**r am familiar with the provisions contained in Section 2-482 of the Miami Beach City Co ing requirements. Signature of Lobbyist: — Signature of Principal/Client: VI. LOBBYIST IDENTIFI ATION: PRINCIPAL IDENTIFICATION: IE Produced ID TCVAq612 lJC,WS _Produced ID Form of Identification Form of Identification IE Personally known(Lobbyist) Personally know (Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County o State of Florida, County of Miam' p� ARTIN�q/i,� Sworn to n subscribe f ' " XIMENA GONZALEZ Sworn an subscribed before M, �sSIONF�A cc This day Public-State of FloriO# This 390'6-day of �c t4,20/0N, My Comm:Expires Mar 24.2017 - ? mission # FF 00111?9 ign lure o Pu lic N ry 'of �e,,... ...,,.._ Signature of Public Notary—State f F #EE1768� :Q` Notar atio of Lobbyist s signature Notarization of Principal's signature °�°•.?gr 86ri 0�R.�e; Public TO BE COMPLETED BY CITY CLERK'S STAFF ONLY =�pUB CST Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# C1 Date Paid Lobbyist Registration Form received and verified by: Y FACLER\$ALL\aFORMS\LOBBYIST FORMS bbyist Registration Porifi,doc C oriii.doc Revised I/I1/2011 MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139,w"w.miamibeaclifl.gov CITY CLERK Office CityClerkamiamibeachfl.gov Tel: 305.673.7411 , Fax:305.673.7254 LOBBYIST NAME: Kobi Karp 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 ty Commission on Ethics and Public Trust. (, 13 _ 06 Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Exhibit A 14 LA GORCE LLC Name & Address Percentage of Stock Lynmarsh Investments Limited 99.9% Geneva Place Waterfront Drive P.O. Box 3175, Road Town Tortola, British Virgin Isles Brett Palos 0.01% 100 George Street, London W1U 8NU LYNMARSH INVESTMENTS LIMITED Name & Address Percentage of Stock Lynmarsh Trust 100% LYNMARSH TRUST Name & Address Percentage of Stock Beneficiary: Cristina Green 100% 24 Avenue Princess Grace, MC 98000, Monaco Trustees: Appleby Services, Ltd. 22 Victoria St., Hamilton, HM EX, Bermuda Individual Directors of Appleby Services, Ltd., Kiernan Bell, Timothy Faries, Rory Gorman, Rodney Boddy, Bradfield Adderly, Cameron Adderly, Farah Ana Ballands, Timothy Counsell, and Frances Woo.