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Graham Penn - JHPSB Collins Ventures, LLC MIAMI BE H . City f Miami Beach Office of the City Clerk tY tY 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. Penn Graham NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell & Fernandez, PA 200 South Biscayne Blvd., Suite 850 Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5300 (305) 377-6222 apenn @brzoninglaw.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: Jason Halpern NAME OF PRINCIPAUCLIENT: JHPSB Collins Ventures, LLC 184 Kent Avenue, C706 Brooklyn NY 11249 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (212) 687-3444 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: g�S®p'+ Ha fff'n • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR M RE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: cep Ct'�'�� II.SPECII=IC LOBBY ISSUE: Development Board Approvals for 302/310/320/336 Collins Avenue, Miami Beach, FL 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,st Ing the general nature of the subject contractual relationship. Sec 2-482(x)(4) Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied Planning Staff, PB, HPB, BOA, DRB, Commission None Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,jamiAi`a-1 or professional relationship,or other relationship giving rise to an appearance of an Impropriety,with any current city commissioner-ok citoersonnel who Is sought to be lobbied as Identified on the lobbyist registration form filed. Sec 2-482(g)Any Financial, Familial or Professional Relationship - N '� cl) C:\Users\clerhatMppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\LobbYst Rg�stration Formrevised 5-30-2012.doc s rjj. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER). A) LOBBYIST DISCLOSURE:(Required) �4wbt) r hue. B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (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 pending bid for aoods.equipment or services,or on a present or uendina 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 X No: Are you lobbyina on a pending application for a Development Agreement with the City or application for change of zoning map desianation 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 No: 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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH THE PRECEDING CAL9bjj2AR YEA13. A ST HALL BE FILED EVEN IF THEBE HAVE BEEN NO �B EXPENDITURES OR Signature of Lobbyist I do solemnly swear that all of the for9gemp facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beac City ode an I reporting requirements. Signature of Lobbyist: Signature of Principal/Client: - VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: s m Produced ID o o Produced I D 0 Form of Identification a 0) o W Form of Identification Z c� . Z, ZPersonally s known(Lobbyist) .E o ✓ Personally known(Principal) . r C 0.1 d VI1. SIGNATURE AND STAMP OF NOTARY. 9.M 1-co a "@. Z Z w Nlw Yak SN-�olK. r :�47 State of Florida, County of Miami-Dade °°' , State of Fla,County of Miami-Dade o 1 o Sworn t nd subscrib b fore me Sworn and subscribed before me z A 0 This of G1! ,2014 ,,.�, This 3rA day of s .�o6A,,2014 A v Signat re of Pu lic Notary—State of Florida Signature of Public otary—State of Florida Notarization of Lobbyist's signatur' Notarization of Pnncipal's signature P-WA Annual Registration fee: [ ]Yes[ ' ]No Amount Paid$ MCR# , ,Date Paid Lobbyist Registration Form received and verified by: C:\Users\clerhatKAppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc F:�CLE istration Form.doc Revised 04/27/2012 MIAMIBEACri 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: Graham Penn 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 automati su pended from lobbying until all fines are paid, unless the fine has been appea d to the iami- a Coun y Commission on Ethics and Public Trust. Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc - - Au t S OC �,r --� Co Vc- OEM O _U > - � � a SUPPLEMENTARY DISCLOSURE OF INTEREST Interests in JHPSB Collins Ventures, LLC Percentage of Interest 295 LNP, LLC 15.78% 184 Kent Avenue, C706 Brooklyn NY 11249 PSB Collins, LLC 84.22% 555 Madison Avenue, Suite 508 New York NY 10022 Interests in 295 LNP, LLC Percentage of Interest The Jason Halpern Life Insurance Trust 90% 184 Kent Avenue, C706 Brooklyn NY 11249 Jason Halpern 10% 184 Kent Avenue, C706 Brooklyn NY 11249 Interests in The Jason Halpern Life Insurance Trust Percentage of Interest Jason Halpern 100% 184 Kent Avenue, C706 Brooklyn NY 11249 Interests in PSB Collins, LLC Percentage of Interest Dhruv Piplani 100% 555 Madison Avenue, Suite 508 New York NY 10022