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Monika Entin - 2912 Collins Avenue Y NAIAMI BEACH City of Miami Beach Office of the City Clerk V' 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. Entin Monika NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell&Fernandez, P.A., 200 S. Biscayne Blvd., # 850, Miami, FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-377-6237 305-377-6222 MEn tin(@BRZo ni naLa w.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: 2912 Collins Avenue, LLC NAME OF PRINCIPAL/CLIENT: 1065 Kane Concourse, Suite 201 Bay Harbor Islands FL 33154 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 866-7555 X305) 866-7515 robertnafinvarb.com TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] I ell • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: Robert Finvarb 9 • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See Attached II.SPECIFIC LOBBY ISSUE: Development Approvals and Permitting Issues, including, but not limited to Historic Preservation Board, Planning and Board of Adiustment approvals for the provertu located at 2912 Collins Avenue,Miami Beach,FL Issue to be lobbied(Describe in detail): Ill. CITY AGENCIES/INDIVIDUALS 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 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 None B, DRB, HPB, BOA, City Commission, and Land Use None Development Committee, as necessary None 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 None None f / l R IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required): $330.00 per hour B PRINCIPAL'S DISCLOSURE OF LOBBYIST COMPENSATION): $330.00 Per hour (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 X No: Are you lobbying on a present or oendina bid for aoods.eauioment or services.or on a present or °en�dina,award for aoods.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 lobbvina on a oendina application for a Development Aareement with the City or auolication La change of zoning mao 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 o: Are you reoresentina 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 = THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILE® EVEN IF THERE HAVE BEEN NO EXPENDITURES OR QOMPENSATION DURING THE REPORTING PERIOD. Signature of Lobkfyist I do solemnly swear that all of the foregoing facts are true an nd that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all orting requireme ts. c Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENT CATIO PRINCIPAL IDENTIFICATION: ®Produced ID ��.:: .'a "��. Produced ID Form of Identification r -;: • = Form of Identification Personally known(Lobbyist) ,Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: Z Rw� State of Florida, County of Miami-Dade z State of Florida,County of Miami-Dade ��' Sworn_14 and subscria=ZA Sworn and subscribed bef r me This ay of 013 This da of ` ,2013 E._ A � � O Sig ure, f bli otary—State of Florida Signature of Public Notary—State of Florida = ••.. Notarizat10 f Lobbyist's signatur Notarization of Prince c®signature .,... [:�_�Pqoqfrafgnn fpp- j I Yes J I No Amounf Paid S a!i 0 TO BE COMPLET MITI(CLERK'S STAFF O Lobbyist Registration Form received and verified by. D S F:�CLE istration Form.doc Revised 04/27/2012 MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Rafael E.Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Monika Entin 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- ounty Commission on Ethics and Public Trust. 5 Signature Date CITY OF MIIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1.CORPORATION If the property which Is the subject of the application is owned or leased by a CORPORATION, list the principal stockholders and the percentage of stock owned by each. Where the principal officers or stockholders consist of another corporation(s), trustee(s), partnership(s) or other similar entity, further disclosure shall be required which discloses the Identity of the Individual(s)(natural persons)having the ultimate ownership Interest in the entity).* 2912 Collins Avenue,LLC, a Delaware Company 1065 Kane Concourse.Suite 201,Bay Harbor Islands,FL 33154 CORPORATION NAME and ADDRESS NAME,ADDRESS,AND OFFICE %OF STOCK RIF 2912,LLC J 00% 1065 Kane Concourse,Suite 201 Bau Harbor Islands,FL 33154 REF 2912 LLC 1065 Kane Concourse,Suite 201,Bay Harbor Islands.FL 33154. Robert gnvarb Family Investments 100% 1065 Kane Concourse,Suite 201 Bau Harbor Islands,FL 33154 Robert FYnvarb Family Investments 1065 Kane Concourse,Suite 20I.Bau Harbor Islands,FL 33154 Robert and Rochelle Flinvarb,Manaaina Members 100;b as 1065 Kane Concourse,Suite 201 tenants by the entirety Bau Harbor Islands.FL 33154 Seville Acquisition,LLC 10400 Fernwood Road,Bethesda,Maruland 20817 Co urrt mrd Marriott Corporation 100% 10400 Fernwood Road Bethesda,MD 20817 Courtuard Marriott Corporation i Marriott International,Inc. 100°6 10400 Fernwood Road Bethesda,MD 20817 Marriott International,Inc. Marriott International,Inc. 100°,6 Marriott International,Inc. is a nubliclu traded comoanu under the sumbol MAR on the New York Stock E=hanae, IF THERE AREADDIlMONAL CORPORATIONS,LIST OTHERS,INCLUDING CORP.NAME(S)AND EACH MDMDUAL S NAME ADDRESS, OfFICEAND PERCENTAGE OF STOCK, ON SEPARATFPAGE. NOM Notarized signature required on page 8 6