Michael W. Larkin - S.F. Land, LLC M1AMIBEACH
5 Co)1;'-05/6K ,
City of Miami Beach Office of the City Clerk i�r''' .- u
1700 Convention Center Drive, Miami Beach, FL 33132015 DEC AN i :
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.
Larkin Michael W.
NAME OF LOBBYIST: (Last) (First) (M.I)
Bercow Radell&Fernandez 200 South Biscayne Blvd., Suite 850, Miami, FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)374-5300 _ mlarkinabrzoninalaw.corn
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
S.F. Land. LLC
NAME OF PRINCIPAL/CLIENT:
6565 Collins Avenue, Miami Beach FL 33141
BUSINESS NAME AND AUUKESS (Number and Street) (City) (State) (Lip Code)
(305) 866-8855 irasussman(athe-beach.net
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 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 propertu located at 6565 Collins 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
yL
• �-
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER)
A) LOBBYIST DISCLOSURE:(Required)
$525/hour
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). $525/hour
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 Dendina bid for aoods.eauipment or services.or on a present or
pending 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 lobbvina on a Pending application for a Development Aareement with the City or application
flu 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 AS COMPENSATION RECEIVED. IN THE CITY OF MIAMI BEACIL
QB THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PER
\__/
Signature of Lobbyist I
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 reporting require ents.
Signature of Lobbyist: \�
Signature of Principal/Clien
VI. LOBBYIST IDENTIFICATION: ,,,5 ',N PRINCIPAL IDENTIFICATION: ` �� 5 ; ,�
�`yOiL '�ti MO"'Produced ID %; 0�= X Produced ID v� e 4,- ��
Form of Identification """''-%i;,,;,,,,'`, Form of Identification �'�`:°; *'3.
,Personally known(Lobbyist) 3 0 Personally known(Principal) 3 0
3 -ow a sZ
VII. SIGNATURE AND STAMP OF NOTARY: H
R. T° 1 H m o rn
�'
State of Florida,County of Miami-Dade '� H d State of Florida,County of Miami-Dade '� y y m—r1 Oa XI
Sworn t• and subscrib befo a me c s Swor l - d subsc ' ed efore me o o z
This w i •,-y of_ Q ,2015 0 �, This � � d.y • ,2015 �,► T n
01- ET Aga • NAG / / ' i 01 NI 01 fr
Sin. ru a -'';lic a State of Florida Sig, urn o •�iA" •
Sign- �• '� ry— g �' ��- ry—State of Florida
Nota zation Lobbyist's signature N N.,.riza io c7': .ti •: ' signature
TO BE COMPLETED BY CITY CLERK'S STAFFIONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ 35� MCR# )q 54 4 _Date Paid
Lobbyist Registration Form receive ,and verified by. � — i io((
I
1
F:\CLE istration Form.doc Revised 04/27/2012
MIAMI 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: Michael W. Larkin
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.
Signature: Date:
CITY OF MIAMI BEACH
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.*
S.F. Land, LLC.
CORPORATION NAME
NAME AND ADDRESS %OF STOCK
S.F. Land Trust_f/b/o Joel Sussman Family 40%
6565 Collins Avenue
Miami Beach, FL 33141
S.F. Land Trust f/b/o Ira Sussman Family 50%
6565 Collins Avenue
Miami Beach, FL 33141
S.F. Land Trust f/b/o Perri Stern Family 10%
6565 Collins Avenue
Miami Beach, FL 33141
CORPORATION NAME
NAME AND ADDRESS %OF STOCK •
IF THERE ARE ADDITIONAL CORPORATIONS, LIST OTHERS,INCLUDING CORP. NAME(S)AND EACH INDIVIDUAL 4
STOCKHOLDER'S NAME,ADDRESS, OFFICE AND PERCENTAGE OF STOCK, ON A SEPARATE PAGE.
NOTE: Notarized signature required on page 8
6
• •
CITY OF MIAMI BEACH
DEVELOPMENT REVIEW BOARD APPLICATION
DISCLOSURE OF INTEREST
2.TRUSTEE
If the property which is the subject of the application is owned or leased by a TRUSTEE,list the beneficiaries of the trust and the
percentage of interest held by each. Where the beneficiary/beneficiaries consist of corporations(s), another trust(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.*
S.F. Land Trust f/b/o Joel Sussman Familu
TRUST NAME
NAME AND ADDRESS %OF STOCK
Matthew Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
Elizabeth Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
Benjamin Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
Stephanie Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
•
S.F. Land Trust_f/b/o Ira Sussman Family
TRUST NAME
NAME AND ADDRESS %OF STOCK
Mollie Sussman Davis 10%
6565 Collins Avenue, Miami Beach, FL 33141
Paige Sussman Danowit 10%
6565 Collins Avenue, Miami Beach, FL 33141
Max Sussman' 10%
6565 Collins Avenue, Miami Beach, FL 33141
Rachel Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
Miriam Sussman 10%
6565 Collins Avenue, Miami Beach, FL 33141
S.F. Land Trust f/b/o Perri Stern Famili
TRUST NAME
NAME AND ADDRESS %OF STOCK
Meredith Rishty 10%
6565 Collins Avenue, Miami Beach, FL 33141
3. PARTNERSHIP/LIMITED PARTNERSHIP
If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHIP, list
the principals of the partnership, including general and limited partners. Where the partner(s)consist of another partnership(s),
corporation(s), trust(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.*
PARTNERSHIP or LIMITED PARTNERSHIP NAME
NAME AND ADDRESS %OF STOCK
NOTE:Notarized signature required on page 8
7
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Miscellaneous Cash Receipt
} CITY OF MIAMI BEACH
X344
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(THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
..,. By
Account Number 011'rC;(A) - c IL\Lt
' Ic - rV' Dept: C (if/k� EXT: 911)
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the rEM(S): Ol MCR_Cjty�
Check (00pp177 �' $1050 00 Cler
Have a n� PAID $1050.00
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