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Kent H. Robbins - Mato Colak 7 MIAMI BEA � . City Of Miami Beach Office of the City Clerk V6� 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. Robbins Kent Harrison NAME OF LOBBYIST: (Last) (First) (M.1) 1224 Washington Avenue Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)532-0500 (305)531-0150 khr @khrlawoffices.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: Mato Colak. NAME OF PRINCIPAUCLIENT: 1820 James Avenue, Apt. 6E Miami Beach Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 276-7362 matoco305@hotmail.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: N/A 7' IDENTIFY• IDENTIFY ALL PERSONS HOLDING,DIR CTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: Legal Representation of Mato Colak,concerning HPB File No.7463,HPB File No.7465 and BOA File No.3742,concerning City of Miami Beach Board Approvals for the property located at 1775 James Avenue,Miami Beach,Florida. 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 Zoning Board of Adjustment None Planning Board None X esign Keview boara Land Use Board None X Planning Staff None X Mayor 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(9),Any Financial,Familial or Professional Relationship Historic Preservation Board d •-? Ul d;LL F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc d°t�o8/LO/ti 1 - C IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $565.00 / per hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). $565.00 / per 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 XNo: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoning map desi-gnation 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. YesXNo: 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 CO PENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHAkt St FILED EXEtfIF THERE.HAVe BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. () le Signature of Lobbyist I do solemnly swear that all of the for go* g facts are e, nd correct ha have read or am familiar with the provisions contained in Section 2-482 of the Miami Bea i Code and I r rting req re Signature of Lobbyist- Signature of Principal/Client: 7, 1 A. z VI. LOBBYIST IDENTIFI ATION: PRINCIPAL IDENTIFICATION: `��r,�41111Pfe��p�� Produced ID �� NANIER '�r,. Produced ID Form of Identifica+ �@ .••••°. G,�`''� Form of Identific�t�pk� °�C01�MISS/p,�.• r9 �'� � e Personally known(Lobbyist) - ® rnN: _ Personally known(Princip ° � a 22 Nom•• n o VII. SIGNATURE AND STAMP OF NEE191409 ,. ' 9�,oG 'Ah 1st S Ato. I °a:V VEE191409 c State of Florida, County pf Miami-Dade �i,� 8��•''°'• �. �� State of Florida, C my of Mia74'o5io l cl �Ah \�5��• Q �� Sworn subscrib d'bef rem vl ��ii°A°1STATE a �� Swor subscri ed efor 'G °° TAo.�OQ`�`�� T i _ day of Y This�ay o am MAC igna ure of Public Notary— tate of Florida 41na®re f Public Notary— ate of Florida Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ V1 No Amount Paid$_-JFjD. CO MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORM \LOBBYIST FORP+S\Lobbyist Annual f&a1RF-,frnYr3V Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc 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: Kent Harrison Robbins 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 automa cally suspended from lobbying until all fines are p id, nless the fine has been app I to th ml-Da o ty Commission on Ethics nd ublic Trust. Signature: ate: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc 7--_'. „T,�- _ _� _ _4:"T_.._....�._ -�.r-�.T':n...-�..-.. .r.-� Tr_�.,.-....--•T,•�-mr.-^`-corn..... MI.Scellaneous Cash:Receipt. i_ CITY OF MIAMI BEACH ": No. =: a Cash Credit Card Q Check# ` :k 20 ' Received of h� �, � `!�� A Address _ For t `�; L s .w.�s ,,� .A�_io _ (THIS INFORMATION.MUST.BE.COMPLETED) Office of Finance Director.: ' VA, n U Account �Number. � # ��'. �e_t a re parer 1390 F EXT