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Jose L. Gomez - Anthony Moonen (61,1 AccirilcotAe., I BEA i City of Miami Beach Office of the City CIeric0[5 of I 0 P 2: 02 1700 Convention Center Drive_ , Miami Beach, FL 3.3Y139 ifi 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. Gomez Jose L. NAME OF LOBBYIST: (Last) (First) (M.I) Beilinson Gomez Architects P.A., 8101 Biscayne Boulevard, Suite 309, Miami, FL 33.138-4664 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305 559-1250 305 551-1740 'a C?i .1 e l f - e[ .011 TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, ore-mail address. I. LOBBYIST RETAINED BY: Anthonu Moonen NAME OF PRINCIPAUCLIENT: 1691 Michigan Avenue Investment, LP, 1185 Avenue of the Americasl8th Floor, New York, NY 10036-2601 BUSINESS NAME AND ADDRESS (Number and street) (Ulty) (State) (Lip(ode) 305 672-6936 305 672-6947 •e.t. moonen(u`colli.rs orb 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 Exhibit A • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: 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 necessaru. relatina to the oronertu located at 1691 Michigan Avenue, Miami Beach. Florida. 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 Staff for the Planning Department,Building Department, None. X Public Works and City administration, PB, HPB, BOA, None. X City Commission, and Mayor 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_ C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF/LOBBYIST COMPENSATION WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required)$2 O/ R B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $ 2-S0/1412. (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 XNo: Are you lobbvina on a Present or oendina bid for aoods.eauioment or services.or on a present or pendinq award for goods.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 XNo: Are you lobbvina on a oendina 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 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 JC No; Are you reoresentina 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{ EQE THE PRECEDING CALENDAR YEAR. A STATEMENT S •LL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERI•D, • A Signature of Lobbyist I do solemnly swear that all of the foregoing facts a e true and «•rrect and t at I :ve read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and I reporting .-quir=. - ' 1 • Signature of L:i::::client:Signature of P ' 411111 111 VI. LOBBYIST IDENTIFICATION P INCIPAL IDENTIFICATION: Produced ID ' 'E i;o g Produced ID Form of Identificati. .'_ e c Form of Identification US r 411 Personally known(Lobbyist) .E,It 1 g _ Perso a ly ••. • ir VII. SIGNATURE AND STAMP OF NOT:'• _ Notary Public State of Florida • . Deborah M Lake g v u' . my Commission State of Florida, County of Miami-Dade a S'. lofi009[1 Abf Miami-D-•:; Sworn to and subscribed before me ��••.••,•.,,,� ;,,;:.'• This 9qt►, day ofSEPTET1 ,2015 lito,,% This Y , day of 2015 4 S.4 ki.,ri Si natur:of Public Notary �" • ,, g Notary-State of Florida h ..e. . . .- -. ... - .. ._.4011P 11 41*6:7 A...A./-■.-------........._ g ry-Stat,�of Florida ''••.,,••„�:P'� Signature of Public Nota Notarization of Lobbyist's sign: ure Notarization of Principal's,signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[f]No Amount Paid$P 5 6 MCR# 4 07 ZOO Date Paid - c 30])5- Lobbyist Registration Form received and verified by: IA C.Ovi`^-1%-,- I Am I BEAC City of Miami Beach, 1700 Convotion Center Driv', Mitlllii t3ettell, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Rafael Is, Granado, City Clerk CityClerk @miattjibeachfl.gov Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: Jose L. Gomez 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 f om lobbying until all fines are paid, unless the fine has been appealed to the Miami-Da• - County Commission on Ethics and Public Trust. ALE ./ Signature: D. e: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc Exhibit A 1691 Michigan Avenue Investment, LP 1185 Avenue of the Americas, 18th Floor, New York, NY 10036-2601 CORPORATION NAME and ADDRESS NAME,ADDRESS,AND OFFICE %OF STOCK IVG Immobilien AG 100% Zanderstrasse 5-7 53177 Bonn Germano IVG is publiclu traded the London Stock Exchange under sumbol:IVG:Extra and in other exchanges:IVG • , i AGENT AUTI oRI2ATION LETTER Parcel 1D 02.3234-0040690 Street Address: 1641 Michigan Avenue,Miami Beach,n 33139 Property Owner: 1691 Michigan.Avenue Investments The undersigned,registered property owner of the above reference property,do herby authorize. _loony 1 en.of Colliers Intern ionctl South F1nrida I, C j aietto act on the ownerships behalf and ,� take all actions necessary for the processing,issuance and acceptance of construction.permits, 41) certifications and any and all standard special conditions. Property Owner Address: 1691 Michigan Ave Investment 1,2 1185 Avenue of the Americas 13`"Floor New York,NY 10036 n: TelAttephone: We hereby certify the above information submitted in this application is true:and accurate to the best of our knowledge. / / dal dif11/!ik Or k r Li o Wm .i Se pkryht Po ao 0 Signature of Property Owner P Name of' •petty Owner Date eitiec ii tit Vice. I 0-tit t r 5,CLg rri- State of Ptt d at t County of The foregoing Instrument was acknowledged before me this day of ,2014 By For 1691 Michigan Ave. Investment LP Personally Known or Produced Identification Type of Identification Produced Signature of Notary ,14 Y1. No. 375 of the roll of deeds for 2015 I hereby certify the authenticity of the foregoing signatures g g nature g son the foregoing document of 1. Mrs, Irmgard Linker(signature on the left), born on 29 August 1988, residing in Bad Homburg v. personally known to me, r„- '3. and 4 f�: M 2. Mr. Nico Brocar(signature on the right), born on 17 August 1980, residing in Frankfurt am Main, who identified himself by his valid German:identity card no. 401483386, which signatures were made on 17 September 2015 in my presence. Upon request of the persons appearing, I effected the notarization in the offices of TRIUVA Kapitalverwaltungsgesellschaft mbH, THE SQUAIRE 18, Am Fiughafen, 60549 Frankfurt am Main. i asked the persons appearing if I or any person professionally associated with me priorly or \\,currently acted or acts in the matter which is subject of the present notarization, except as a n* (prior involvement pursuant to Sec. 3 para. 1 no. 7 of the Recording Act (BeurkG)). The pe appearing answered in the negative. I hereby expiiciiy`'\vise that my responsibility is limited to the certification of the authenticity of the foregoing sig a ,.4 s and that I have not reviewed the content of the foregoing docu- ment and thus cannot take esponsibility whatsoever for such content and/or its validity. \\.\ Frankfurt am Malt;. September 2015 jj /1 / ti” Dr. 'arste J. 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N N CITY OF MIAMI BEACH! x y -;- t� ,53 ,a � �' _ �� �{ ?__r "0,, .'-"ice- _ 1 : g'A.2:7,Y:if-'=- 4 i�j ri-i 10110 ❑ Cash ❑Credit Card Check# ` ,_ f , : , ,„‘",./� i ;".c,::-•-,': :::''' • . . \, ,, , - T cyl,,.. 'y' 20 1 e- Received of A'10 4.(IA CA A 1-ti vi 1-0e-,e C O ,,..__r:, Address 910\ : ,' ei. ,,,a. 4 O Af r ' 3 F.Yr,■ i 1 For )( ci z 6‘OA Ago , A/1 Ca - . 1 .)12 of( 2:) 1 sctA e S : : , i . .., [ - , :,. - .1 (THIS INFORMATION MUST BE COMPLETED) - Office of Finance Director BY c z�1:... . 1.._ - - fir., - Account Number t -':"3,0:-.43r,-- ,' if _2(..L..... ' .' Pre.arer:� p Dept: ' xr i.ii_ r .- . .- _ : ., effi F. rr AINIEMINWNSIKIIIIIMINNIMPIVW miesavir City of Miami Beach-Florida Finance Department 1 City Hall 1527320-1 09/30/2015 BR1 T131 Wed Sep30,2015 02:05PM Trans#35-35 35 $700.00 MCRCLERK - MCR-City Clerk MCR#: 407200 1 ITEM(S): TOTAL: $700.00 Check (002392) PAID $700.00 Have a nice day! •