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Jeffrey S. Bass - Bath Club Entertainment, LLC /\AIAMI BE r 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. Bass Jeffrey S NAME OF LOBBYIST: (Last) (First) (M.1) Shubin & Bass,P.A. 46 S.W. 1st Street, Third Floor, Miami, FL 33130 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)381-6060 (305)381-9457 jbass @shubinbass.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: Bath Club Entertainment,LLC NAME OF PRINCIPAL/CLIENT: Bath Club 5937 Collins Avenue,Miami Beach,FL 3 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)381-6060 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: R.Donahue Peebles,Managing Member Eladio Izquierdo,Vice President&Secretary • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: Board of Adjustment File No.3646-Appeal of administrative decision regarding the types of uses permitted at the pool deck of the Bath Club Issue to be lobbied(Describe in detail): III.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 eneral 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 Miami Beach Board of Adjustment N/A 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 Relationshi p N/A -° Q F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $635/hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $635/hour 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 ✓No: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or pending award for goods,equipment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes ✓No: Are you lobbying on a pending 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 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✓No: Are you representing a not-for-profit corporation or entity without special com ensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT T HE Y C A SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WEL PENS ON REIbElyft,IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEME SHALL BE FILED EVEN4F TAERIE HAV EN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Si u e of Lobbyis do solemnly swear that all of the foregoing facts are true and correc d that I have read o f ar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting re m S. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID Produced ID Form of Identification Form of Identification ✓ Personally known Q, M euoyeN y6no,ul popaog , - , ✓Persona ZZSl9933#.:u01$siww00„- ao� �N r0ll��`7+ NotaRD tate of VII. SIGNATURE AN EjT6 ,QFSM1RTj-@b6bb Aw:= , Emiique • • e u0 0 2¢ -01 AR ION =�” "'= ��'' My C EEO 1 P. IJ L l IS 10d 1 N .... �8n 'EOi rid' fi 14 State of Florida, County of iami- p*V100 Hjnll State of Flor Sworn to and subsc' Sworn nd subscr�ed a ore me y ebrua 12014 This day of b , 201-L4 Signature of P- ary—State of on a Si ub' Notary—State of Florida Notarization of Lobbyist's s' nature Notar Principal's signature TO BE COMPLETED BY CITY CLERKA STAFF ONLY_ , Z/ //Ll Annual Registration fee: ]Yes[ ]No Amount Paid$ M C R# n Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc " _ . MlAtOIBEACH 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: 305.673.741 1 , Fax: 305.673.7254 LOBBYIST NAME: Jeffrey S. Bass 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 2485 (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 2485.1, a fine of$50.00 a day shall be assessed for all Statement(s) fled 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 t the required Statement by April 30th, 2012, shall be automatically suspen d m lobbying until all fines are paid, unless the fine has been appealed to the mi- d ounty Commission on Ethics and Public Trust. February 28, 2014 Si atbre. Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc i — Q . - :o N _: m Aw !� .. s�. - } a Lu 0 IL saw f � — a -e c ® 3 .� -� z z d �0 cN0 m � . v1 c m V C MIAMI City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov City Clerk's Office Tel: 305-673-7411 Fax 305-673-7254 Office Use Only ANNUAL LOBBYIST REGISTRATION FORM Name: Jeffrey S. Bass Business Name: Shubin & Bass, P.A. Address: 46 SW 1 st Street, Third Floor, Miami, FL 33130 Office Telephone Number: (305) 381-6060 Cellular Telephone Number: (305) 381-6060 Email Address: jbass@shubinbass.com If more than one lobbyist,please list: 1) 2) 3) 4) 5) 6) 7) Submit this form to the Office of the City Clerk, along with a check for $500 for each lobbyist. Please make the check(s) payable to the City of Miami Beach. For City Clerk's Office Use Only MCR#: 3�2 Z Amount P aid: Q Date aid: �z P Processed by: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\ANNUAL LOBBYIST REGISTRATION FORM reg.docx