Adrian K. Dabkowski - Shore Club Property Owner LLC �a01 CUin54'x.i
MIAMIBEACH
<,28/6.
City of Miami Beach Office of the City Clerk/i , , ` ,
1700 Convention Center Drive, Miami Beach, FL 33139,'x; , /0.
LOBBYIST REGISTRATION FORM q r +a (J,.. 0-9
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the pasage, 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 K.
NAME OF LOBBYIST: (Last) (First) (M.I)
Kimley Horn 600 North Pine Island Road Suite 450 Plantation, FL 33324
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
954-535-5144 asullivan @mcsal.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, ore-mail address.
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
Shore Club Property Owner LLC 600 Madison Ave, 17th Fl New York NY 10022
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
212-300-8013
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: Laurie Golub
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST I�v SUCH CORPORATION,
PARTNERSHIP OR TRUST: 1, 2. i epOVve,�W €iS .A9r'�`Mev'..# enp� VPVttVvi'l c�1'rJ
II.SPECIFIC LOBBY ISSUE: "i
Zoning,Land Use Approvals for Shore Club Hotel )q 0 ( (49kkiv,.4 .6kkle
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
Historic Preservation Board,Miami Beach Commision,Board of Adjustmn is X
Public Works,Design Review Board,City Manager,Public Works 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 No
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RAVE,,OR��OTHER):,,
4//, /�) .
A) LOBBYIST DISCLOSURE:(Required) g -,_, '/ , ,
'15,40110z 1.c.
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B) PRINCIPAL'S DISCLOSURE OF LOBBYIST COMPENSATION): ,1�, , ' '
(REQUIRED). 117 3•i0 MK ,. �•
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The following information must be answered: ///,_,
1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procureent
Issues":
_Yes XNo: 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 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.
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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
i
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 de and - -;;.'rting requirements.
1 Signature of Lobbyist: `� '�— —
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Signature of Principal/Client: AR
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VI. LOBBYIST IDENTIFICA11ON: PRINCIPAL IDENTIFICATION:
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a�Produced ID FLOgi' 1 1 P1 U€ IS Ct C( C 4 Produced ID d�r , Ure,
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known(Principal)
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g g V SIGNATURE AND STAMP OF NOTARY:
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` ft§ of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
..yal n to 4.• subscribed before me / Sworn acid subscrib d e Qre me
r. day of 1! i , 201(`� Th' R 1 day of A Ej\ , 201-S
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'^_;L,.[=ture of Public Notary—State of Florida Si. atu e Public Notary—State of Florida
`' ''�' � .rization of Lobbyist's signature Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ Yes[ ]No Amount Paid$ 0t1 MCR# 0 4 4 Date Pa*
Lobbyist Registration Form eceived and verified by: Pet G �; ' '1.,�e F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration(Form.doc f '� KRISTIN' !J? a`t7�/22 2014
„ )• . MY COMMISSION#FF116B13
'4'.•.•'..d EXPIRES April 27, 2018
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(401)398.0153 FlorldallotaryService.com
M1AMBEACH f.:..
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamideachfl.gov
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CITY CLERK Office 4/3v/r)
Rafael E. Granado, City Clerk CitNXIerk @miarchfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254 ` « -.9
LOBBYIST NAME: Adrian K. 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 of each year, 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.
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ignature: Date:
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CITY HALL CASHIER OFFI
1700 CONVENTION CNTR DR
MIAMI BEACH, FL 33139
04/14/2015 10:38:19 ....-.
.... -
Merchant ID: 000000005148978
Terminal ID: 02013135
275202450886 Beach-Florida
CREDIT CARD Finance City of Department
MC SALE
CARD# 4259 1 City Hall
INVOICE 0009 1510413-1 04/14/2015 BR1 T134
Batch
INVOICE Tue Apr 14,2015 10 38AM IrtalrICR4-2C13it-20
001512 20 $2550.00 MCRCLERK y Cler
Approval Code: 53968P * MCR#: 403444
Entry Method: Swiped Credit 1 ITEMS)Car: TOTAL:PAID $2550$2550.00
Mode: Online .00
SALE AMOUNT $2550.00 Have a nice day!
CUSTOMER COPY