Jeffly G. Molina - Fairfax Hotel Partnership, LTD cJ,G
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 331304 10 PH
2: 08
LOBBYIST REGISTRATION FORM < < i CL, °„I �,
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Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, �a.efed't-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.
Molina Jeffly G.
NAME OF LOBBYIST: (Last) (First) (M.1)
1470 South Michigan Avenue, Chicago, Illinois 60605
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(312)912-5430 gabriela @jefflyart.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:
Fairfax Hotel Partnership, LTD
NAME OF PRINCIPAUCLIENT:
Fairfax Hotel Partnership, LTD, 444 N. Michigan Ave, ##3500, Chicago, IL 60611
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(3 12) 2 67-4 191
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: Steven C.Florsheim,President
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: See Attached Exhibit
II.SPECIFIC LOBBY ISSUE:
Placement of Sculpture at 1776 Collins Avenue, Miami Beach, FL 33139
Issue to be lobbied(Describe in detail):
lll.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
City of Miami Beach Historic Preservation Board None X
City Manager and his staff None X
Planning Director and his staff 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 Any Financial,Familial or Professional Relationship
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) No additional compensation for lobbying.
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): No additional compensation for lobbying.
(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 &o: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or pendina
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 No: Are you lobbying on a pendinq 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 2481 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 tNo: 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 SHA ILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
,r,L/X 0
Signature o s
do solemnly swear that all Pf th egoing facts are true and co m&and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miarr i e e and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Clie t'
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
o
Produced ID El Produced ID
FoA of Identification P Form of Identification
mgsz �.-
❑ Personally known(Lobbyist) s o, C Personally known(Principal) M
�o m.Z..
z al
VII. SIGNATURE AND STAMP OF NOTARY: m a.?Q v,
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me 3 Sworn and subscri before me
This `Q- day o , 2014 This sday of r 2014
N
Aec-L i„
Signature of Public Notary–State rids Signature of Public Notary–State o
Notarization of Lobbyist's signatur4j Notarization of Principal's signature
- Z TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: Yes[ ]No Amount P WC R,# Date Paid 1
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual gistration Fo m.doc Revised 1/11/2011
DISCLOSURE OF INTEREST
3. PARTNERSHIP/LIMITED PARTNERSHIP
If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED
PARTNERSHIP, list the principals of the partnership, including general and limited partners. Where the
partner(s) consist of another partnership(s), corporation(s), trust(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.*
Fairfax Hotel Partnership, Ltd.
PARTNERSHIP or LIMITED PARTNERSHIP NAME
NAME AND ADDRESS %OF STOCK
FAIRFAX HOTEL PARTNERSHIP, LTD.
LEVY FAIRFAX,LLC 97%
Lawrence F.Levy 3%
LEVY FAIRFAX, LLC
LEVY FAMILY PARTNERS, LLC 100%
LEVY FAMILY PARTNERS, LLC
LFL HOLDINGS, INC. 1%
LEVY FAMILY 1997 SPECIAL TRUST 5%
LAWRENCE F. LEVY 2003 FAMILY TRUST 20%
LEVY FAMILY 1997 SPECIAL TRUST NO.2 34%
ARI LEVY 2012 IRREVOCABLE TRUST 10%
ANDREW FLORSHEIM 2012 IRREVOCABLE TRUST 10%
ROBERT FLORSHEIM 2012 IRREVOCABLE TRUST 10%
STEVEN FLORSHEIM 2012 IRREVOCABLE TRUST 5%
FLORSHEIM LFP GIFT TRUST 5%
LFL HOLDINGS, INC.
Lawrence F.Levy 100%
LEVY FAMILY 1997 SPECIAL TRUST
Ari Levy 25%
Steven Florsheim 25%
Andrew Florsheim 25%
Robert Florsheim 25%
LAWRENCE F.LEVY 2003 FAMILY TRUST
Ari Levy 25%
Steven Florsheim 25%
Andrew Florsheim 25%
Robert Florsheim 25%
LEVY FAMILY 1997 SPECIAL TRUST NO.2
Ari Levy 25%
Steven Florsheim 25%
Andrew Florsheim 25%
Robert Florsheim 25%
ARI LEVY 2012 IRREVOCABLE TRUST
Ari Levy 100%
ANDREW FLORSHEIM 2012 IRREVOCABLE TRUST
Andrew Florsheim 100%
ROBERT FLORSHEIM 2012 IRREVOCABLE TRUST
Robert Florsheim 100%
STEVEN FLORSHEIM 2012 IRREVOCABLE TRUST
Steven Florsheim 100%
FLORSHEIM LFP GIFT TRUST
Riley Florsheim 16 2/3%
Kaden Florsheim 16 2/3%
Bodie Florsheim 16 2/3%
Logan Florsheim 16 2/3%
Saige Florsheim 16 2/3%
Griffin Florsheim 16 2/3%
BEACH
City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: Jeffly Gabriela Molina
I understand that no later than February 28th ®f 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.
Signatur Date:
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CITY OF MIAMI BEACH
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(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
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