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Jennifer McConney - Washington Ave Associates, LLC C1 IS, cII/Ic hq 91,t 6113, ci 25 ci L17, Ct ss GJA'S+i-1 NcAat) it-/G - Office of the City Clerk 1700 Convention Center Drive Miami Beach, FL 33139 305.673.7411 • • 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 City Code Chapter 2,Article VII, Division 3, entitled "Lobbyists," for additional information. Instructions: Please complete all sections of this form and submit the completed form, with the applicable fee, to the Office of the City Clerk. If you need more space to complete an answer, use a separate sheet(s) of paper. If you have nothing to report in a particular section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form. The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs. Separate registration forms shall be required for each principal represented on each specific issue. I. LOBBYIST INFORMATION: McConney Jennifer NAME OF LOBBYIST (Last) (First) (Middle Name) Kobi Karp Architecture & Interior Design, Inc. 2915 Biscayne Blvd., Suite 200 Miami Florida 33137 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 573-1818 LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Joseph E. Teichman NAME OF PRINCIPAL (Last) (First) (Middle Name) Washington Ave Associates, LLC 1985 Cedar Bridge Avenue, Suite 1 Lakewood, NJ 08701 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS If the principal is a Corporation, Partnership or Trust, the following information MUST be provided pursuant to City Code Section 2-482(c): • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: - ?,v) 1-6 ch o UY • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: 9e alailk III. ISSUE TO BE LOBBIED: Describe with as much detail as is practical, including but not limited to a specific description where applicable of a pending request for proposal, invitation to bid,or public hearing number. Development Approvals and Permitting Issues, including, but not limited to the Design Review Board, Planning Board, Board of Adjustment, Land Use Development Committee, City Commission, and any City Workshops or Committees, if necessary, relating to the property located at 915, 917, 919, 921, 923, 925, 947, 955 Washington Avenue, Miami Beach, Florida IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City personnel sought to be lobbied,and whether the lobbyist has entered into any contractual relationship(paid or unpaid)with said City Commissioner or City personnel from 12 months preceding such commencement of service with the City to the present date, stating the general nature of the subject contractual relationship. Full Name of Individual and Contractual Relationship(If yes,explain) YES NO Title of Person to be Lobbied Staff for the Planning Department, Building Department None X Public Works and City Commission, 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. List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an appearance of impropriety: None V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a contingency fee is prohibited pursuant to City Code Sec. 2-485.3): 4/550/At - The following five(5)questions MUST be answered: 1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _Yes x 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 City Code Section 2-490, entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes x 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 City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481) 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 city 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? 4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. _Yes XNo: Are you providing only scientific, technical or other specialized information; appearing as a representative of a neighborhood association without special compensation or reimbursement or representing a not-for-profit based organization for the purpose of requesting a grant without special compensation or reimbursement? 5) Pursuant to City Code Section 2-482(a)(4), a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particular service before lobbying the City Commission at a public meeting. _Yes£No: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle?If yes,please list the incumbent member(s)of the City Commission: If yes,you must also orally disclose such particular service before lobbying the City Commission at a public meeting. VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD.' Signature of Lobbyist: Date I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Date Signature of Principal: Date CCj122//&' VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of State of NeCA.1 �s� County of: County of: 0C-eAh Sworn to(or affirmed) and subscribed before me Sworn to (or affirmed) and subscribed before me this day of , 2016, by this �day of S 4-ge-►' , 2016, by `J�C2Sepil E 7 Mel- v? NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION _Personally Known ( Personally Known ■ Signature of Notary Public ature of Notary Public Name of Notary, Typed, Printed or Stamped Name of Notary, T ped, Printed gattathiAl SOLL Notary Public,State of New Jersey (NOTARY SEAL) (NOTARY SEAL) My Commission Expires February 28,2017 TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc Revised 08/18/2016 1 The term"lobbyist"specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD.11 Signature of Lobbyist: Date 9/2-6VI(C) I do solemnly swear . affi that II of the for going facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with t e ••rovisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City Code and all re.•-in• .-quireme Signature of Lobbyist: il Date R t t / Signature of Principal: Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: _ PRINCIPAL State of 1O('si ._. State of County of: _CtlY\ AQ.... County of: Sworn to(or affirm ) a bscribed before me Sworn to(or affirmed) and subscribed before me this� day of 2016, by this_day of ,2016, by I NAME OF LOBE 1ST NAME OF PRINCIPAL _Produced ID _Produced ID V FORM OF IDENTIFICATION FORM OF IDENTIFICATION Personally . • ',n _Personally Known ll,l ' _ •- .re of N 'l' Pus is Signature of Notary Public _.3 4. ••••,--:r,lial .o... __ ., . . ._ , Name of Notary, yppwr,rintea orb p@ ORRES �; Name of Notary, Typed, Printed or Stamped 4741 Notary Public-State of Florida I (NOTARY SEAL; , Commission 0 FF 908783 (NOTARY SEAL) � :, My Comm.Expires Aug 12,2019 0 %1:1 i to`r Bonded through National Notary Assn. • — — — ....laic unwed.t-ai on OW&TY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\SALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc Revised 08/18/2016 1 The term"lobbyist"specifically excludes the following persons: Expert witnesses who provide only scientific, technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. M1At\ABEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov Office of the City Clerk Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1, Fax: 305.673.7254 NAME OF LOBBYIST: Jennifer McConney 1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or principal) who fails to file timely a Lobbyist Fee Expenditure and Compensation Statement (Statement). In addition to any other penalties that may be imposed as provided in Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements 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 from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a signed Statement under oath listing all lobbyist expenditures, as well as compensation received, for the preceding calendar year with regard to the specific issue on which I have been engaged to lobby. 2) LOBBYIST WITHDRAWAL Once an issue I have registered to lobby has concluded or I am no longer lobbying on that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk. 3) ANNUAL LOBBYIST REGISTRATION FEE I understand annual registration of all lobbyists shall be required for each 12-month period commencing October 1 of each year, and the fee for such annual registration shall be $500." pur.uant to Section 2-482 of the Miami Beach City Code. 7 /2,6 - ignatur. of Lotbyist Date F:\CLER\SALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 08-18-16 REG.doc .•'54 iscellaneous Cash Receipt CITY OF MIAMI BEACH 41 No. - • - - - , _ , _ - • • -- Cash 0 Credit Card Check# Ot..1 1 -' :35 o - 09 ' 2 20 - City of Mia 4@pgtilyed of - C Cv#i i _ MiscellaneotAdtheifit424 671 5 i3 f C:(1" A.1 17 ,1v(*C 200, 09- (7-1,,, 331 57 000581-0016 Adrian/ 09/27/2016 01:16PM • M CR OPEN For Payment Amount: 350.00 MCR411989 • • - (THIS INFORMATION MUST BE COMPLETED) - Office of Finance Director ----- ; .K.> 3 t— LAI tt on 7 T -: Cr) Aceount Nuniber: 0 J % • Prepeeei: Dept C EXT: #. . _ . • SUPPLEMENTARY DISCLOSURE OF INTEREST Interests in Washington Ave.Associates, LLC Percentage of Interest Washington Ave. Holdings, LLC 100% 1985 Cedar Bridge Ave. Suite 1 Lakewood, NJ 08701 Interests in Washington Ave. Holdings, LLC Percentage of Interest Washington Ave. Holdings II, LLC 100% 1985 Cedar Bridge Ave. Suite 1 Lakewood, NJ 08701 Interests in Washington Ave. Holdings II, LLC Percentage of Interest Washington Ave. Pref. Member, LLC 100% 1985 Cedar Bridge Ave. Suite 1 Lakewood, NJ 08701 Interests in Washington Ave. Pref. Member, LLC Percentage of Interest SAYT Master Holdco, LLC 100% 1985 Cedar Bridge Ave. Suite 1 Lakewood, NJ 08701 EXHIBIT A — LEGAL DESCRIPTION Lots 10,11, 12, 13, 14, and 15, Block 31, of the Ocean Beach Addition No. 2 Subdivision, as recorded in Plat Book 2, Page 56 of the Public Records of Miami-Dade County, Florida.