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Graham Penn - 2901 JMH, LLC j401� to 0. 4,c`^ E 4 d � City of Miami Beach Office of the City Clerk �.s 1700 Convention Center Drive, Miami Beach, FL 33139 -~-1 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-'.revived the the city commission, or a city board or committee. The term specifically includes the Development Board Approvals f it 2901-11 Indian Creek Drive, Miami Beach, principal as well as any employee engaged in lobbying activities. The termf:`Lobtyists" has specific exclusions. Please refer to Ordinance 2004-3435. Penn Graham NAME OF LOBBYIST: (Last) (First) (M.I) Bercow Radell & Fernandez 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(a.brzoninalaw.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: 2901 JMH, LLC 184 Kent Avenue, C706 Brooklyn New York 12249 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 374-5300 iason.eimhdev.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: A.2../7.,e • IDENTIFY ALL PERSONS HOLDING, DIRECTLY R INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: ../19 II.SPECIFIC LOBBY ISSUE: Development Board Approvals for 2901-11 Indian Creek Drive. Miami Beach. Florida Issue to be lobbied(Describe in detail): nL CITY AC,ENCIES/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 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 r�� IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): C A) LOBBYIST DISCLOSURE:(Required):$475.00 ,s._. y a B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):$475.00 i--- °" (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 F rocureri ent Issues": `--:,.1, CR - - �� r.il _Yes X No: Are you Iobbvina on a present or oendina bid for aoods.eauioment or services.or on a present orpending 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 pendina application for a Development Aareement with the City or application for chanae of zonina map desianation or chanae 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 representina 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-- OMPENSATION -ECEIVED. IN THE CITY OF MIAMI BEACH ' Q" ■_ - :_ _p , 1-_4.I _1: ' _11 A■ e►GI-- - - __• - -1 . _ N - : __1 ■ • EXPENDITURES OR - •1i -_1 . • 1 ! ► N_ ■ • Z.4 M.10.: -•• . 7 41WPPw- , , Signature of Lobb I do solemnly swear that all of h- forgoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Plea City Code and all reporting requirements. Signature of Lobbyist: / Si , 9 Y - Signature of Principal/Client: 00 Olt VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: 431 ,,..;\ o +r N it�'a1: :II r Z^ - 'P'r' ' Produced ID Produced ID b sue;...,, S.- °� ' Form of Identification z z r•-• ~' Form of Identification � �� • �j � JPersonally known(Lobbyist) o Cl) -0 0 _+ Personally known(Principal) m '`T' Q w > ('J 07 VII. SIGNATURE AND STAMP OF NOTARY: - � Z cim c'iz. sv Q o u5 State of Florida, County of Miami-Dade i6' 0 z m State of ' , County o e m o z=o Sworn to and subscribed before me - w 71 0 Sworn and subscrib=�• before me a, SI This i =i.- day of ,2015 o ro 0 z This 54 day of Al/ 1 ,2015 o v-E § p w D I I— Z E - p c c° o m 'v` 0 Signature of Public Notary— at f Flo ' S nature of li otary—State of Frlefidg-/1l Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ D No Amount Paid$ . •°o MCR# `'1 094 Date Paid ‘iii 41,5 Lobbyist Registration Form receive6 and verified by: " a4 r'c_ n,•-'— - C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc I F:\CLE istration Form.doc - Revised 04/27/2012 I AA AM ' BEACH . . City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, 4 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 automatically suspended from lobbying until all fines are paid, unless the fine has been appea - •• : • Miscellaneous Cash Receipt } y t`€ 2� 134 0q..tom. P.qp' ??�PaF 3►CV `a;LS w.V' CITY OF MIAMI BEACH - - • , 0 Cash %Credit Card ❑Check# , ;.. $ 5 • • 14 20_ Received of ( t 4!I Ce`vi 1 C I '! Address ZbO c)4t4 1 + <€ ri c. t.,.l.) � For c to . V 6 —c r .2 co, r (THIS INFORMATION MUST,BE COMPLETED) Office of Finance Director t st By f 1 Account Number. .' 1- i;;00 C '364. t`1 L ` EXT: Aii/. • ,. t l / -..--.:ti,e. �_.. .1. .. t. .... .+. .!C', ..tee., r ., r,. i .» + -�'; .,es ., • .�„ 5 t , .. �5'F,.. -- ... .._,,.v,.. . ._..at ..,. CITY HALL CASHIER OFFI R 1700 ONL 33139 MIAMI CONVENTI BEAC ,F Q8:54:32 041142015 000000005148978 Merchant ID: 02013135 Terminal ID: • 1090573940 CREDIT CARD AMEX SALE )0000000000(1057 CARD# 0002 • INVOICE 001512 Batch#1 553114 Approval Code: Swiped Entry Method: Online Mode: $350,00 SALE AMOUNT CUSTOMER COPY