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City of Miami Beach Office of the City Clerk 2015 J1J.Jd=°, -° "s P'1 2: 27
1700 Convention Center Drive, Miami Beach, FL 33139_,.. .. • . .�� ,( --
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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.
Moehring Robert
NAME OF LOBBYIST: (Last) (First) (M.I)
DOMO Studio LLC, 420 Lincoln Road, Suite 506 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-674-8031 robert @domodesignstudio.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
z
I. LOBBYIST RETAINED BY:
Sagaponack, LLC
NA BPRINCIPAUC NT:
ox 402249 Ma
Mom! Beach Florida 33140
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-542-1131 - tmgeng64 @aol.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: see attached
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY gR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION.
PARTNERSHIP OR TRUST: see attached
II:SPE IFIC LOBBY jS E Development Approvals and Permitting Issues, including, but not limited to Historic
Preservaffon Heview boaed, Planning Board, Design Review Board, Board of Adjustment, Land Use Development
Committee and Cit Commission if necessa relatin• to the •rooert located at 2300 Sunset Drive Miami Beach FL.
Issue to be lobbied(Describe in detail):
I 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 , Building, Publlic Works and Fire Dept Staff None X
PB, DRB, HPB, BOA,City Commission, and Land Use
y None X
Development C omitten, as necessary
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
F:\CLERI$ALLIaFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required_
4"/PS .
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMP NSATION):
(REQUIRED). 2!75
The following information must be answered:
I) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
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.
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Signature of Lob yist
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 d all reporting requirements.
Signature of Lobbyist:
g
Si • 1 :
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
.a6,....."..,.:1L..4,....'
roduced ID ' ;-ti`,Q a %= roduced ID 14::17,1,:::4:°1?---:.-
Form of Identification . T 0,TI,� I. Form of Identification = =i �6
;;pq a ,�\\, %‘9 . `�\\�
Personally known(Lobbyist) W ���� ��� - Personally known(Principal)
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VII. SIGNATURE AND STAMP OF NOTARY: a ° ` o I a 3 3 - o
N m Q S ,tp N m v <
State of Florida,County of Miami-Dade o x v : State of Florida,County of Miami-Dade ? a' A v•Sworn and subscribed before me f z ' . o Sworn and subscrib d before me m % N o
This jYof )J'-t. , 201 T n o This l day of ,201 a T n o
�" z ::' ° o r 2. m ° o
F z .' w Z
Signature o i; •lic Notary-State of Florida A o a Signature•.`T7 blic Notary y-State of Florida o
Notarization f Lobbyist's signature ° co 2; Notarization of Principals signature c° [7,
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration_fee: [ I Yes[ J No Amount Paid$.s : .,1 '� MCR# 0-(1.6 Date Paid
Lobbyist Registration Form receive and verified by:
=;\ LIZ\ °LL\aFOR S�.L SIVI ST FORMSI€obb'ist.Annual R i,,ti;:.i; :-MCirt,a8C Revised 01/22/2014
F:\CLERI$ALL1aFORMSILOBBYIST FORMS\Lobbyist Registration Form.doc
•
City of Miami Reach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miomibeachfl.gov
CITY CLERK Office
Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax:305.673.7254
LOBBYIST NAME:
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
falls 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$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th of each year,shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
alb/005'
Signature: • Date:
F:ICLERI$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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•,Y
OWNER AFFIDAVIT FOR INDIVIDUAL OWNER
STATE OF
COUNTY OF
,being first duly sworn,depose and say that I am the owner of the property described and which is the subject
matter of the proposed hearing;that all the answers to the questions in this application and all sketches data and this other supplementary I cation must be completed and
m P P
and made a part of the application are true and correct to the best of my knowledge and belief.I understand application
the sole purpose of posting a
accurate before a hearing can be advertised. I also hereby authorize the take the responsibility of remov removing this notice after the date of hearing.
NOTICE OF PUBLIC HEARING on my property as required by law and I to p
SIGNATURE
PRINT NAME
Sworn to and subscribed before me this day of , 20 . The foregoing instrument was acknowledged before me by
S who has produced as identification and/or is personally known to me and who did/did not take an
oath.
NOTARY PUBLIC
NOTARY SEAL OR STAMP
PRINT NAME
My Commission Expires:
ALTERNATE OWNER AFFIDAVIT FOR
CORPORATION or PARTNERSHIP,
A (Circle one)
STATE OF litit .ty.,Ire
COUNTY OF �''' ' o
1 tvl `� being duly sworn,depose and say thz1.I am the of I g
and as such,have been authorized by such entity to file this application th at all answers to the questions in the our
application and all sketches,data and other supplementary matter attached to and made a part of the application mattee of and
c pro osed heart of We
knowledge and belief;that the corporation is the owner/tenant of the property described herein and is
understand this application must be completed and accurate before a hearing can be advertised.I also hereby used authorize
and iI take Miami Beach b to en er
the subject property for the sole purpose of posting a NOTICE OF PUBLIC HEARING on toe property required by
removing this notice after the date of hearing.
7() v v SIGNATURE
PRINT NAME
ribed before me this day of /1/4/%6N , 20 j . The foregoing instru 'was acknowledg ' before me by
J of Sworn to apd ubsc — on behalf of su entity, who produced
as identification and/or is personally known to me and who did/did not take an oath.
NOTARY SEAL OR STAMP:
DAVID SOLOMON it NOTARY PUBLIC
?a:�,`��, Notary Public-State of Florida `.
•' �!1 i• My Comm.Expires Aug 10.201:s PRINT NAME
�, Illi rte ,:
�- Commission#FF 113494 5e
.r •.,Fos`�o
My Commission Expires: ?,• Bow Ttuaugh National Notary Lssn.r'
4
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•
CITY OF MIAMI BEACH
4/1 DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
1.CORPORATION
If the property which is the subject of the application is owned or leased by a CORPORATION,list ALL of the stockholders,and
the percentage of stock owned by each. Where the stockholders consist of another corporation(s),trustee(s),partnership(s)or
other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having
the ultimate ownership interest in the entity.*
iit-eck7OAN 1
Spa Pok/A;( LL C
CORPORATION NAME
NAME AND ADDRESS %OF3TOCK
iAnulAN 6°
Yh N
/MI ci i IL
VAVIV kl WL 5O* 13/20547 Pi(LW.. cog,
P49. R) 4O721q
trl lM( 33/4O
16' 61447 ev,
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CORPORATION NAME
NAME AND ADDRESS %OF ST 95K
K
614)tr /446,‹ \AO 'IN
,! _ IA t ,_ ; _ o
.
IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL
STOCKHOLDER'S NAME,ADDRESS, OFFICE AND PERCENTAGE OF STOCK ON A SEPARATE PAGE.
NOTE: Notarized signature requi'ed on page 8
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