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Adrian Dabkowski - M-4000 Alton Owner, LLC fri MIAMIBEACH 1/000 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. Dabkowski Adrian NAME OF LOBBYIST: (Last) (First) (M.I) Kimley-Horn &Associates 600 N. Pine Island Road, Suite 450 Plantation Florida 33324 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (954) 535-5144 adrian.dabkowskikkimlev-horn.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)] ��nn C) • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: G ✓n �� V i4 i b' - crs p�'l 7 .1 • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: - II.SPECIFIC LOBBY ISSUE: -m, y Development Board Approvals for 4000 Alton Road, Miami Beach, FL , . Issue to be lobbied(Describe in detail): -; .•Y off L� Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: -1 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 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(g)Any Financial, Familial or Professional Relationship NONE 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)$ I"'3•s S Div B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST OMPENSATION): (REQUIRED).$ 173 rise t-%.01. ,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 lobbvina on a present or pending bid for goods.eauioment or services.or on a present or pending award for goods.eauioment 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 lobbvina on a pending application for a Development Agreement with the City or application for change of zonina map designation or change to the City's Future Land Use Mao? 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 Efa3 THE PRECEDING CALENDAR YEAR. A STAT MENT SHALL BE FILED EVEN IF THERE HAVE BEAN NO, EXPENDITURES OR •u• . _ •■ • 1. z •• k • •! _- - . A1S10. --- Si•''�ure 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 Cit Code .nd all reportin • ents. Signature of Lobbyist: A _ r Signature of Principal/Client: Ti amilo ig r.,Presid ot•M-4000 Alton MUR,LLC,Manager of M-4000 Alton Owner,LLC VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: fg Pro uced ID Produced ID o 0 Form of Identification Form of Identification > .w (n (o O N U N y @ c5 Personally known(Lobbyist) ,Personally known(Principal) z.0 t , o o e VII. SIGNATURE AND STAMP OF NOTARY: ` ,- " \ pro 5, z02w State of Florida !•un Miami-Dade State of Florida, County of Miami-Dade ,�/�'"47%, ty Miami Sworn - :u- Crib,• a .?i SHANDA SUTTON LAYNE Sworn and subscribed before me 4p. • o �. day of ,4., �I 1 This�23"t da of 2015 '1", ' This '��' -MY COMMISSION#FF 092573 o Ja , F1_•�..��. a /��." :° •Bonded Thru Notary Public Underwriters i .,...,,,,,,,. al, - •f Publ, Notary Signature of Public otary- tate of Florida Notarization of J.,obbvist's signature Notarization of principal's signature TO E CO PLET D ITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# (If !,J I Date Paid 2 /4.--- Lobbyist Registration Form received and verified by / o C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc F:\CLE istration Form.doc Revised 04/27/2012 M1AMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, 4 www.miamibeachfl.gov CITY CLERK 0 ffice Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME Adrian Dabkowski 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 automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. 2,-/Z3// Signature: Date: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Exhibit B Disclosure for Talmudic College 4000 Alton Road, Inc. A Florida Non-Profit Corporation Rabbi Yitzchak G.Zweig,President 4000 Alton Road,Miami Beach,Florida 33140 Ira N.Hill,Vice President 4000 Alton Road,Miami Beach,Florida 33140 Yehuda Zweig,Secretary 4000 Alton Road,Miami Beach,Florida 33140 SUPPLEMENTARY DISCLOSURE OF INTEREST Beneficial Ownership Interests in M-4000 Alton Owner. LLC Alicia L. Jarrett 73% 100 S Pointe Dr.#3804 Miami Beach, FL 33139 Camilo Miguel, Jr. 24% 119 Washington Avenue, Ste. 505 Miami Beach, FL 33139 • City of 8fiami Beach-Florida Finance Department :,:.„.,,,,,, A. 1 City Hall 1505513-1 02/24/2015 RR] 1125 rue Fe524,2015 11:53581 Trans#55-55 55 -$850.00 NCRCLEpK - �, * HCR : 401498 1CR-City Clerk i ITF81(S), TOTAL: $850.00 neck (OO1206) FAID $850.00 Have a rice day! �..�.. _......:- ,: �.-�•:•, !;' ^e'e`l';.t -fY - .Y.],c _ .tr �..i't - - ^ j Miscellaneous Cash Receipt g y _f �. 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