Charles H. Benson - 6080 Collins, LLC &Ott) (Oitio5.Avetot.c.
NAIAm I BEACH
Q
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.
Benson Charles H.
NAME OF LOBBYIST: (Last) (First) (M.I)
Charles H. Benson&Associates, Architects, P.A., 1665 Washington Avenue, 2nd Floor, Miami Beach, FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 532-6161 (305)532-6151 carkitect3aaaol.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:
Flavio Rossato
NAME OF PRINCIPAL/CLIENT:
6080 Collins, LLC 1815 Purdy Avenue#3 Miami Beach FL 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
786-888-1702/ 786-355-3849 cell frossato(a�domusarounusa.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,DIRE TLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: see 4 tie&
II.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues, including, but not limited to the Historic Preservation Board, Design Review
Board,Planning Board,Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or
Committees. if necessary. relatina to the oronertu located at 6080 Collins Avenue. Miami Beach.Florida.
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 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 Department and Building Department Staff None. X
PB, HPB, BOA, City Commission, as necessary 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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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)$ 2.S.-&62
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): 0-c9-2°
(REQUIRED). .
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)(No: 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)(No: Are you lobbvina 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 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 BEACI{
E$ THE PRECEDING CALENDAR YEAR. A STATURE k SH• •L B FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR •t■• ► 1 •■ B : ■ • •: : TI ,
Er ii C
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 Code and all repo,in.'resift e
Signature of Lobbyist:
0
Signature of Principal/Client: bat
_ . • PRINCIPAL IDENTIFICATION:
We LOBBYIST IDENTIFICAT N �_ R E
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• Produced ID r ::; Produced ID 1 .g
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Form of Identification - t Form of Identification
o �`- • lid,' . ' v �a
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i8 i ='Personally known(Lobbyist) ' • X Personally known(Principal) :y cn D
SIGNATURE AND STAMP OF NOTARY: • • `� x ,12.
`''"'F- '-' of Florida,County of Miami-Dade °`.:`'�'','�•;, State of Florida,County of Miami-Dade
- '• .,:rn to and subs -• • • e me f�°•' •e` Sworn and subscribed before me ;e� • , q•'"' a• is '7 •:y of ' 2015 o°S' 4.•' This I'_, •ay of On ,2015 :1 '0
' , '44E110" qta i Signature o 'ublic Nota a e of Florida Signature of P b is otary-State of Florida
Notarization o • • i ' signature Notarization of principal's,signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
2
Annual Registration fee: [ ]Yes[X]No Amount Paid$ 111P MCR# 40N)V7 Date Paid
Lobbyist Registration Form received and verified by: .i)cKao\Vro-
•
m Am, BEACH
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: Charles H. Benson
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.
(5--)a.„____‘._
Signature: Date:
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Formrevised 5-30-2012.doc
CITY OF 1,4AC 1
DEVELOPMENT REVXEW iz0.1
•
DISCLOSURE OF INTEREST
1. CORPORATION
If the property which is the subject of the application is owned or leased by a CORPORATION, list the principal
stockholders and the percentage of stock owned by each. Where the principal officers or 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).*
6080 Collins, LLC
CORPORATION NAME and ADDRESS
NAME, ADDRESS, AND OFFICE %OF STOCK
6080 Collins Manager, LLC 100%
4700 Sheridan Street, Suite J
Holltwood, FL 33021
60870 Collins Manager, LLC
CORPORATION NAME and ADDRESS
NAME, ADDRESS, AND OFFICE %OF STOCK
URBIS Management Corp. 50%
4700 Sheridan Street, Suite J
Holluwood, FL 33021
Domus Holdings, Inc. 50%
1815 Purdtl Avenue, #3
Miami Beach, FL 33139
Refer to Exhibit C, attached hereto
IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS, INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL'S
NAME, ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE.
NOTE:Notarized signature required on page 8
6
•
ti
EXHIBIT
URBIS MANAGEMENT CORP.
Title VST `E
HOBERMAN, PABLO
4700 SHERIDAN ST STE J
HOLLYWOOD, FL 33021
Title PST
RAKOVER, ALEJANDRO
4700 SHERIDAN ST STE J
HOLLYWOOD, FL 33021
•
DOMUS HOLDINGS LLC
Title MGR
R. POWER HOLDINGS INC.
6000 COLLINS AVE. APT 316
MIAMI BEACH, FL 33140
Title MGR
ROSSATO, FLAVIO
6000 COLLINS AVENUE 316
MIAMI BEACH, FL 33140
R POWER HOLDINGS INC
Title PD
ROSSATO, FLAVIO
6000 COLLINS AVE. AP. 316
MIAMI BEACH, FL 3314
= _ 1 000a- , 001 105
;: Miscellaneous Cash Receipt . _
:.t 1 k 4.1A4: 17: I-,650.0J,�
CITY OF MIAMI BEACH a oP
® Cash - 0 Credit Card Chec k°# y 1) D
vim 2 201
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Received of /01.Cirlae.r.-) bir kir% ittiCn."It 144; -
Address 13J .( iL e olAc , g„, .{
For 60 SC co(h h.n i �1 14
(THIS INFORMATION MUST COMPLETED) _
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Office of any Director..
By.
Account Number: P
(1e fPre arer: f J Dept• a� EST: