David E. Sacks - 1446 Ocean Drive MB, LLC I4 b 0citsAA t ��
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MIAMI BEACH
2016 /b:
City of Miami Beach Office of the City Clerk 21,r y , ,?(-1
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1700 Convention Center Drive, Miami Beach, FL 33139 . • 0i
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.
Dav i-d r Scvrks
NAME OF LOBBYIST: (Last) (First) (M.I)
►'s P / Q S'. lc's«u (3!u . oc�f ��1a�)t, rL 3-3/3
BUSINESS NAME AND ADDRESS ' (Num er and Street) (City) I (State) (Zip Code)
3+ - 3 9- 7-4 2 31)5 - 'x'19- Z 4-2-0
TELEPHONE NUMBER: FAX NUMBER: EMAIL: •
Please notify this office if your contact information changes:address,phone,or a-mall address.
I. LOBBYIST RETAINED BY:
iyu, D -4- D- ' - LL- �-
NAME F I CIP LIENT:
B SIN SS NAM AND ADD ES (Number and Street) (City) ( ate) (Zip ode
A tIVE bL\ m\oralcrk,G \e C vr �
TELEP ONE UMBER: FAX NUMBER:(Optional) EMAIL: Option I)
Fill out this section If principal Is a Corporation,Partnership or Trust(Section 2482(c)] I
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: Mb a YI M rvtc �D h e f k a f/
• IDENTIFY ALL PERSONS HOLDING,DIRECTL INDIRECTLY,A 5%OR MORE OVERSH113 INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: MD Aa-114 D&'ai/k-0-4"
ii.SPECIFI LOBBY ISSUE: k la.runWt CAno ZOn it' f n Cx'hnutt,, Ion 1N i4-1.‘
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
'l
(3f)04,(15 ('pir�mr 'Cf:es - I �
3-1-q
Pursuant to City eode 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
F:\CLER\$ALL1aFORMSILOBBYIST FORMS\Lobbyist Registration Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) qg//r
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSAT ):
(REQUIRED). `t"9)
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 vNo: 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 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?
1 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 0: 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 E ,THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIO
ure f bytst ..--"■._
■
I do solemnly swear that all of the foregoing f, re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 o - - v .t _-ch City .d' d all reporting rr irements. .
Signature of Lobbyist:
Signature of Principal/C ent:
VI. LOBBYIST IDENTIFICATION: RINCIPAL IDENTIFICATION:
_Produced ID —Produced ID
Form of Id ,[1fI AAiT Form of Identification
4tii" DORINDATRIPONEY
?.: • .r_ MY COMMISSION•FF 24382
coJ
Personally known(Lobby's W.._�c:., EXPIRES:July 10:2019 _Personally known(Principal)
-%;p/Gd'` Bonded Thru Notary Puhtic Underwriters
VII. SIGNATURE AND STAMP riu a FlIC t.
State of Florida, County of Miami-Dade State of Florida,County of Miami-Dade
Sworn to a d subscribed before me Sworn and subscribed before me
This day of -101 ,201! This day of ,201_
iOLI.Ai� . 1"
Signat' - of Public Notary-Sta( of Florid. Signature of Public Notary-State of Florida
Notarization of Lobbyist's signature - Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY /
Annual Registration fee: [ ]Yes[1]No Amount Paid$ 350 • V rd1CR# HI 0 7i41 Date Paid 157-'/4-/6
Lobbyist Registration Form receive and verified by: -i(SO1J SA/AIM(LC:,
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
•
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) liglitr
B) PRINCIPALS DISCLOSURE(OF LOBBYIST COMPENSSAT/Q�
(REQUIRED). QV.) /�
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 vi o: 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
evelopment Issues":
_Yes .A/13: 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.
_Yes 'It : 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 EV .THERE HAVE BEEN NO EXPENDITURES OR
OM E S I N DURING HE REPOR G ER
ut�`tSt bylst > /_
I do solemnly swear that all of the foregoing f re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 o -- • .r • -: •ch City •d all reporting r frements.
Signature of Lobbyist: _ �,..., - Z
Signature of Principal/C ent:
VI. LOBBYIST IDENTIFICATION: RI CIPAL IDENTIFICATION:
_Produced ID _Pr.. ced ID
Form of Id nrt -r ° Form of Identification
:4h�ry , DORINDATRIPONEY
W....,,„,"; MY COMMISSION#FF 224382
_Personally known(Lobby! _ F EXPIRES:July 10,2019 Personall known(Principal)
WOW Bonded Titre Notary Public UMenniters
VII. SIGNATURE AND STAMP r lw I Mr%r.
State of Florida,County of Miami-Dade State of Florida,County o 6 iami-D-de
Sworn to a d subscribed before me Sworn and subscribed before
This day of 5�(y ,201 C. This day of 201_
�J QiSignal of Public Notary-Sta of Florid Signature of Public Notary-State of Florida r
Notarization of Lobbyist's signature Notarization of Principal's,signature IC. /
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY 'I`C/
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid `
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014
F:ICLERI$ALL\aFORMSILOBBYIST FORMSILobbyist Registration Form.doc
ACKNOWLEDGMENT
A notary public or other officer completing this
certificate verifies only the identity of the individual
who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or
validity of that document.
State of California
County of Orange )
On July 7, 2016 before me, Rachel Strokosz, notary public
(insert name and title of the officer)
personally appeared Mohammad Honarkar
who proved to me on the basis of satisfactory evidence to be the person(s)whose name(s) is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the
person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing
paragraph is true and correct.
WITNESS my hand and official seal. •�, RACHEL STROKOSZ
Commission#2087782 =;
J Notary Public-California
-ti/ Orange County
_^' , Q L ,� ` Comm. ires Oct 26 2018
Signature C 4 1 ' (Seal)
MAM1 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: CUta 5L 5
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 of each year, shall be
automatically suspended fr obbying until all fines are paid, unless the fine has been
appealed to the Miam' ade County Commission on Ethics and Public Trust.
-gnat Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
Miscellaneous Cash Receipt
CITY OF MIAMI BEACH 410747
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No
❑ Cash ❑Credit Card ®Check#
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Miscellaneou'�a �'^Q_1'C� �
000305-002f9 is B. 4 - 9:4
MCR OPEN
Payment Amount: 350.00
MCR410747
THIS INFORMATION MUST BE COMPLETED) Office of Finance Director
By •
Account Number.
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57;1-V r G Dept: G EXT= 741/f
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