Alyssa Kriplen - M-4000 Alton Owner, LLC t 1 ��
t% lVV/
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.
Kriglen Alvssa
NAME OF LOBBYIST: (Last) (First) (M.1)
Shulman +Associates 100 NE 38 Street, Space 2 Miami Florida 33137
BUSINESS NAME AND ADDRESS Number and Street)) (City) (State) (Zip Code)
(305)438-0609 (305)438-0170 Alvssald�shulman-design 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:
Camilo Miguel Jr.
NAME OF PRINCIPAUCLIENT:
M-4000 Alton Owner, LLC 119 Washington Avenue, Suite 505 Miami Beach Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 531-2426 (305) 675-8447
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: Camilo Miguel,Jr.
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:Mast Property Investor II, LLC //!?
lIV o —
If.SPECIFIC LOBBY ISSUE:
Development Board Approvals for 4000 Alton Road, 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,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 Staff, PB, HPB, BOA, DRB, Commission None —y y
i�
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent of any business,financial,f; gmon
milial'or professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city nel who is
sought to be lobbied as identified on the lobbyist registration form filed.
;:::, CJ i
Sec 2-482(g)Any Financial, Familial or Professional Relationship T;
NONE
I i %1 7 0 i'7
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$ per hour $
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.eguipment or services,or on a present or pending
award for aoods,eauipment 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 lobbying on a pending application fora 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 X No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement.
V. SIGNATURE UNDER OATH:
FEBRUARY ON 28 OF EACH C B I CJJY CLERK
LISTING LOBBYINQ EXPENDITURES, AS WELL AA WMPENSATIQN RECEIVED, IN THE CITY OF MIAMI BEACH
FOR THE PRECE12ING CALEbIDAR YEAR. A SIATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPEbISATION DURING THg REPO IOD.
Signat rZ Lob%ad t
I do solemnly swear that all of the f regoing facts are true and rect t at I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Be c ity Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID =° = Produced ID
Form of Identification =;9,•,.•,,.� Form of Identification
Personally known (Lobbyist) g Personally known (Principal)
o � d
e3 �
VII. SIGNATURE AND STAMP OF NOTA :y. - m
N
Cr
State of Florida, County of Miami-Dade °* State of Florida, County of Miami-Dade
Sworn to and subscribed befo e T c- a = Sworn and subscribed before me
This f 014 N s x This day of , 2014
co W T
Go
d N O
Q 1
Q
Signa pre of Public otary-State of Florida °D °' Signature of Public Notary-State of Florida
Notarization of i 's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [Vj Yes[ ]No Amount Paid$ �-0 7 MCR# 37061 Date Paid k
Lobbyist Registration Form received and verified by: („_Z(Z-0 9-
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$ per hour
P Pte ' cwt r
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). r
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 lobbYi,ng on a present or pending bid for goods,eguipment or services,or on a Dresent 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 X 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 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
EM THE PRECEDING CALENDAR YEAR, A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach City Code and all reporting-requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
oco
Personally known(Lobbyist) X Personally known(Principal) 0 3 0
m y Uj Ln
VII. SIGNATURE AND STAMP OF NOTARY: o N
o
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade a'Q E
Sworn to and subscribed before me Sworn and subscrib d before me o a
This day of , 2014 This 546 day of V ,2014 z°v tZ
e
o�
Signature of Public Notary—State of Florida Signature of Public Notary—State of Florida o
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid
Lobbyist Registration Form received and verified by:
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
istration Forrn.doc Revised 04/27/2
City of N—lial"i Reach, 1700 Convention Center Drive, Miami Beach, Florida 313139, 4,.�-V%,-xv.nilarilibeactill.�ov
CHA' CLERK Oflice
Rafael E. Granado. Cit-v Clerk CitNClcrk:c i,,-,nilaniibeaciifl.p-ov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: -Alyssa Kriplen
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
auto 'cally suspended from lobbying until all fines are paid, unless the fine has been
app ale the Miami-Dade County Commission on Ethics and Public Trust.
Sig f at Dah%,..
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
1185
11/5/2014
Original Amt. Balance Due Discount Payment
350.00 350.00 350.00
0!1
Check Amount 350.00
tea+ `
City a-, P�1iani Beach-F iol`ida
F i Nance Depa rtfrient
4.
143(')920-11 11/05/2014 BIRI rl'28
��-ed NOV05,2014 02.53PM Trans#9"-5
g $8;o,00 `,irRrLERK - MCP-City Clerk 4000 Alton 350.00
mC'R#: 3 67 $650
Credit 'Car PAID $500.00 1185
};eck (00111 85) PAID V50,00 11/5/2014
Original Amt. Balance Due Discount Payment
140Ve a nice day' 350.00 350.00 350.00
Check Amount 350.00
JP Morg; Miscellaneous Cash Receipt
'RODUGTDLT104 CITY OF MIAMI BEACH
No.- 37067-
❑ Cash Credit Card /Check# :9 -3 ®6
�7 20_
Received of r! P Pine
Address
For A-Y-,n r -� i �: — -�-° �c i.� C�t�. } ►";; .
(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
BY
Account Nurnber:
Preparers (�; "
Dept: �-=�- EXT: �� 1