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Ian G. Bacheikov - Gary A. Friedman • I AIM %&,e, ail •48 City of Miami Beach Office of the City Clerk ,? I J � 2-6 9°; 1 , 1e 1700 Convention Center Drive, Miami Beach, FL 33-139 LOBBYIST REGISTRATION FORM I f ,i i•,L ` ' ` ' �" 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. Bacheikov Ian G. NAME OF LOBBYIST: (Last) (First) (M.I) Law Office of Ian G. Bacheikov, P.A. 945 Pennsylvania Avenue, 1st Floor; Miami Beach, Florida 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305)249-8000 (305)249-9000 ian @bacheikov.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: • Gary A. Friedman NAME OF PRINCIPAL/CLIENT: 117 Palm Avenue, Miami Beach, FL 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 446-6485 friedman.qary@yahoo.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: nJ/fr • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE:, Variance for accessory building size and area and all other_land use,zoning,development,and licensing matters related to the property commonly known as 117 Palm Avenue. Issue to be`lobbied-(Describe in detail): lll.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 City of Miami Beach Board of Adjustment None X Planning Director and his staff 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 ./ • ' v 0 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) • $250/hour B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $250/hour (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 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? 3) Pursuant to Miami Beach City Code 2-484(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 © No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: • ON FEBRUARY 28th 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 F D EVEN IF T E E HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. I ' .-<:...:(,,) �►i Signature of Lobbyist c I do solemnly swear that all of the foregoing facts are tru- 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 - orb . requp ents. Signature of Lobbyist: _ —411111LI 411■ Signature of Principal/Client: _ v VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: • ❑ Produced ID _ _ _ _ _ 0 Produced ID For o w1 )ca io Form of•,�:.ir*cation SUSAN LOPEZ • I o ev P �( JASON SCHOENHOLTZ I .: :. MY COMMISSION#FF 942420 .? UB Notary Public-State of Floiida N '�•`? -'i`-: EXPIRES:January 24,2020 ' [X Personally known (Lo )'!` :•= Commission U FF 938174 Personally known(Pri 41) Bonded Thru Notary Public Underwriters 1 ,� I'I'11 •a� ' 4,,��a�: My Comm.Expires Dec 14,2019 ! VII. SIGNATURE AND ST MP'(1 '�1!•OTAR through National Notary Assn. State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade Sworn to and subscribed before me Sworn and subscribed before me This day of i�,c,ory2016 This `2 O pay of iOn , 2016 it e b1ic Notary-State of Florida ignature of Public Notary-Stat Florida d,:. ..:01161 of Lobbyist's signature otarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF 0 LY Annual Registration fee: Yes[ ]No Amount Paid$ IS d.dv MCR# Date Paid b/-,2A-I Lobbyist Registration Form eceived and verified by: Q OM SA/Seta G. F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist_Annual Registration Form.doc Revised 1/11/2011 W IV\ AMiBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax:305.673.7254_ LOBBYIST NAME: Ian G. Bacheikov, Esq. I understand that no later than February 28th 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, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. 1 Lo f Signature: sate: • • I Miscellaneous Cash.Receipt _q 6 CITY OF MIAMI BEACH_ ,r N0. - _ -Check# 1' -Tn 7 0 Cash 0 Credit Card : 2 ,jk� _ '-, I. 6. 20 i ' Received of - ,,, cL. Li 5 .1. .:. Is = , l „ ..1,:pi t /1--4 531 _ ; f; ,- Address For Of�tce of F6nance Director (THIS INFORMATION MUST BE COMPLETED} By • i ri Account Number w7 S% _ r 3h�.r r , 1 CL ' t;•mot f: _ P ,;y ti v I ,.. ' Dept: - _ _ reparer: ' . Cu if-" CD : :3 co C Or " n a, rT fD N n r+- ^ tO� N " n O �• p -- ' N) 11 co• a 0 -. .S �a q- o r �n o CD Ln O 1 3 3:::. 1 li : - W O p i C C ND 7 CD CD Z \ LAW OFFICE OF IAN G BACHEIKOV PA 1077 C_Jk_ (3c-Th ) 00 7 g6 0 ct -- LAW OFFICE OF IAN G BACHEIKOV PA 1077 1 I PRODUCT SSLT104 USE WITH 91663 ENVELOPE 87 FD7814 STXRX7 11/19/ O1, 03:20 L I J