Graham Penn - JHPSB Collins Ventures, LLC -ai/316/3a613
MIAMI B
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City of Miami Beach Office of the City Clerk } _` f
1700 Convention Center Drive, Miami Beach, FL 33139
2015 KY -'7 pi-1 3: 58
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the 1passage,-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 aDennabrzoninalaw.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, ore-mail address.
I. LOBBYIST RETAINED BY:
Jason Halpern
NAME OF PRINCIPAL/CLIENT:
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: Jason Halpern
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNFRSHIP OR TRUST. See Attached
II.SPECIFIC LOBBY ISSUE:
Development Board Approvals for 302/310/320/336 Collins Avenue. Miami Beach. FL
Issue to be lobbied(Describe in detail):
Ill. 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 X
None X
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
NONE
NONE
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required)$475.00 per hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): I y 7�„Ad T��
(REQUIRED). 1 �1O4�
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 oendina bid for aoods.eauioment or services.or on a present or Aendina
award for aoods.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 Iobbvina on a Aendina 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
• _ ■ • ►, ► .II - A �' 1/ 'ENSATION RECEIVE4Q,jNauLraTY OF MIAMI BEACI j
EQR . . : _ 1 - . . _ : _ L ; - RE HAVE BEEN NO
EXPENDITURES OR • II '_. • ► r ■ • • : ►. : • ea:
d
Signa .r- o' byist
I do solemnly swear that all . e fore.•ing fa .re true d correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the M'=mi Beach • ► -mot!= all -sorting requirements.
Signature of Lobbyi iMM
Signature of Principal/Client:
I/
VI. LOBBYIST IDENTIFICA • PRINCIPAL IDENTIFICATION:
cr o� Notary Public state of Florida
_Produced ID Diana Ramos
Form of Ident My�O"'4`�1a 201gaa�19 Produced ID Form of Identification
'�oo w°' ExPlrea 0
Personally known(Lobbyist) BRIAN G.BR!, •erson IIy known(Principal)
Publlc,,State of New Yor�C
VII. SIGNATURE AND STAMP OF NOTARY: Notary Na®1BR8181227
®1141ed h Sliolk Count�l 4- (
State of Flo 'ea,County of Miami-Dade 0L1 ount of e
Swo to . d.ubscribe bef re me CommIsSl®n pir�Sworn a subscnb y ore me
Thi ; day of r) 1 ,2015 This day of� ,2015
k
lr?g^- 1 ,i0 4.---/'
Sign:`ure of 'ublic Notary—State of Florida Signature of Public Notary—State of Florida
Notarization of J..obbvist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ No Amount Paid$ Z�.•°E' MCR# `t°'�(1 Date Paid ��7I5
Lobbyist Registration Form receive and verified by: (_✓
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IF:\CAE istration Form.doc Revised 04/27/2012 I
M1AMBEACH
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 penalties a y 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
appeale• to e iami-D. County Commission on Ethics and Public Trust.
-.L>t</
___-Sig ature: Date:
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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
h 01% CHI 175
::Miscellaneous Cash Receipt , f;•Y,� Y4.� #0411 Y ,050.00
CITY OF MIAMI BEACH ,
No
fr?45'45
❑ Cash ❑Credit Card Check.# $ 59
- A11,. 20 /
Received of r C 'f LC d( I t'1u hh5 g eo 0 Cara i en s
Address
Fort j t 55 ti ts De' B®04 ct0.D o1ctlS. 102-13i 6 2
(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
Account Number:
• } ,.�; De t: f c.I-- EXT: ?Li!,
Preparers P
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