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Robert Martin Moehring - Martini Realty LLC 4)-(-) s. RECEIVED tv\IAMIBEACHOCT 22019 Office of the City Clerk 1700 Convention Center Drive CITY OF MIAMI BEACH Miami Beach, FL 33139 OFFICE OF THE CITY CLERK 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: Moehring Robert Martin NAME OF LOBBYIST (Last) (First) (Middle Name) DOMO Studio LLC, 420 Lincoln Road, Suite 506 Miami Beach Florida 33139 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-674-8031 305-984-3624 robert@domodesignstudio.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: MANA MOISHE NAME OF PRINCIPAL (Last) (First) (Middle Name) llark;,C P-0.3LLC l /J s F�►3ts��s f7 t`l1 ) t ct Y 15 PRINCIPAL BUSINESS AME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-573-0371 Leslie@manamiami.com 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(if none,write N/A): See attached • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST(if none,write N/A): See attached Page 1 of 5 Development Approvals and Permitting Issues,including,but not limited to Historic Preservation Review Board, Planning Board,Design Review Board,Board of Adjustment,Land Use Development Committee,and City Commission, if necessary,relating to the property located at 1635 W 22nd Street,Miami Beach FL 33140. /1g 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 Historic Preservation Review Board, Planning Board, Design Review Board, Board of Adjustment, Land Use Development Committee, and City Commission, if necessary, relating to the property located at 420 S Hibiscus Drive, Miami Beach FL 33139. 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 Planning , Building, Publlic Works and Fire Dept X Staff PB, DRB, HPB, BOA,City Commission, and Land X Use Development Comittee, as necessary 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(if none,write N/A): 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): $250/hr Page 2 of 5 The following six(6)questions MUST be answered: 1) Pursuant to City Code Section 2-488, entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _Yes 1,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": _Yes4No: 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'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 / No: Are you providing only scientific, technical or other specialized information; appearing as a 1� 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 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s) for whom the campaign consultant provided campaign consulting services within the past election cycle. See Section 2-491 for more information. _YesHave 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: Yes 1o: If yes, has it been less than 12 months since the elected official(s) whom you provided campaign consulting services was sworn in? 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2-491) 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: Yes_4io: If yes, were you promised or did you receive economic consideration in exchange for campaign consulting services? TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [k]Yes[ ] No Amount Paid$ a -y`, •`fit-' MCR# t. 2-1 +5 � '\ Date Paid ;/Cc') 01— (tA Lobbyist Registration Form received and verified by: 4)(1-504 Snt,1•415& F:\CLER\$ALL,\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 01-01-18 REG.doc Revised 01/01/2018 Page 3 of 5 • 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: 4/1/1e1----- ------ Date /0/1///9 i 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. (-}a)kihe. Signature of Lobbyist: Date it) //// Signature /J� Signature of Principal: /"{0,4 . Date / tsri/At9-19 VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State �t Florida State of Florida County of: Miami Dade County of: Miami Dade Sworn to (or affirmed)and subscribed before me Sworn to(or affirmed)and subscribed before me this / - day of 6 C1-1, r-- .204 by this f *day of ©e i a 7 tCr2— ,20L1 by Robert Moehring Moishe Mana NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF it r� IFICATION FORM OF ICENT4FICATION X Personally Know X Personally Known J . Signature of Notar qr, c Signature of Notary(P..hilc j .vk V oc-vrtl , v t ::, r�oMot4 Name of Notary, Typ•d, Printed or Stamped Name of Notary,T ped, Printed or Stamped ( 5 SEAL)ut $..__ aosti9 (N TA�t EMY o,/' ;._. � S � Jnr COM,:is ,.. 1C• _ `181 The to o yist"specifically exc u es he 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. Page 4 of 5 MIAMIMIAMIBEACF 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: mo--e--4-4146 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 $500.00 pursuant to Section 2-482 of the Miami Beach City Code. /1•66///14,/\ _.. /o/o 07 Signature of Lobbyist Date F.\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 01-01-18 REG.doc Page 5 of 5 Page 4 of 8 OWNER AFFIDAVIT FOR INDIVIDUAL OWNER STATE OF FLORIDA COUNTY OF MIAMI DADE I, , being first duly sworn, depose and certify as follows: (1) I am the owner of: the property that is the subject of this application. (2) This application and all information submitted in support of this application, including sketches, data, and other supplementary materials, are true and correct to the best of my knowledge and belief. (3) I acknowledgeand agree that, before this application may be publicly noticed and heard by a land. development board, the application must be complete and all information submitted in support thereof must be accurate. (4) I also hereby authorize the City of Miami Beach to enter my properly for the sole purpose of posting a Notice of Public Hearing on my property, as required by law. (5) l am responsible for remove this notice after the date of the hearing. SIGNATURE Sworn to and subscribed before me this day of , 20 The foregoing instrument was acknowledged before me by , who has produced as identification and/or is personally known to me and who did/did not take an oath. NOTARY SEAL OR STAMP NOTARY PUBLIC My Commission Expires: PRINT NAME ALTERNATE OWNER AFFIDAVIT FOR CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY STATE OF F.gi:M COUNTY OF !44s - 114 04/ I, ,ucq t'14.i4 , being first duly sworn, depose and certify as follows: (1) 1 am the I44,44 410l1 l•fifilitn (print title) of t.ijar2mvia V±Ck7y LLL (print name of corporate entity). (2) I am authorized to file this application on behalf of such entity. (3)This application and all information submitted in support of this application, including sketches, data, and other supplementary materials, are true and correct to the best of my knowledge and belief. (4) The corporate entity named herein is the owner of the property that is the subject of this application. (5) I acknowledge and agree that, before this application may be publiclynoticed and heard by a land development board, the. application must be complete and all information submitted in support thereof must be accurate. (6) I also hereby authorize the City of Miami Beach to enter my property for the sole purpose of posting a Notice of Public Hearing on my property, as. required by law. (7) I am responsible for remove this notice after the date of the hearing_ SIGNATURE Sworn to and subscribed before me this . i' 'day of Tic/ , 20 1 . The foregoing instrument was acknowledged before me by kuis.fg u/1 , who has rettileee Na Z �ppt Wel as o •;• s ser ono nown o me and ho:di• 4'4-not-take an oath. ff 4•µr.a,�.,, JAY Ctr VNt] .S tIOR*TAIVIR of ri0,5. � / in) Commrssio n#cc NOTARY PUBUC • ,civ ,• My COMM I xoires hq I t. We ore committed to providing excellent public service and sofety to aft who Ara,work,and play in our vibrant,tropical,historic community. Page 6.f 8 filed, but prior to the date of a final public hearing, the applicant shall file a supplemental disclosure of interest, DISCLOSURE OF INTEREST CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY If the property that is the subject of the application is owned or leased by a corporation, partnership or limited liability company, list ALL of the owners, shareholders, partners, managers and/or members, andthe percentage of ownership held by each. If the owners consist of one or more corporations, partnerships, trusts, partnerships or other corporate entities, the. applicant shall further disclose the identity of the individual(s) (natural persons) having the ultimate ownership interest in the entity. Alert NAME OF CORPORATE ENTITY NAME AND ADDRESS %OF OWNERSHIP _ t r NAME OF CORPORATE ENTITY NAME AND ADDRESS %OF OWNERSHIP If there are additional corporate owners, list such owners, including corporate name and the name, address and percentage of ownership of each additional owner, on a separate page. We are committed to providing excellent publk service and safety to all who fire.work,and ploy in our vibrant tropical,historic community: MBF o City Hall 1700 Convention Center Dr. 23 �`'� `� , L Q Miami Beach , FL 33139 N '\`� 305-•673•-7420 0 Welcome N 1 ., �� m 003942-0009 Adrian V 10/02%2()19 08 3%AM N (,\ „ t j ir o MISCELLANEOUS o ET) fk Description: MCR OPEN z 40V a 0 (NCR) 1 Reference 1 : MCR424824 MCR OPEN (MCR) v1 i' 2020 Item: MCR 1 C' 1) 1 0 850.00 " )\ MCR OPEN (MCR) 850,00 J r 850.00 "'\ ^ r • Mr p Subtotal 850.00 W 0 Total 850.00 Y w CHECK 850.00 a s I�Q _t Check Number1804 d U 1 Change due 0.00 _ �--. I`� Paid by: DOMO STUDIO LLC tn V U o S 2 ,J cy !111111 itli!!li�lliillllilli SHIN!il,llliiii Il!IIII!I 0 ` v �' a as a anansruaouc "^"�' 1804 2 w 1 $ .o Z Z IMN eMC'.i f.17111 ' ID`J7 (n _'V C E Zr. lf.SLvt'W,4 AAu t _S` .ii,;ft 0 U o ,, ' V = d MAY. 1(..xf*' s!r � fit o &u. a H i i Atrwr *4.t...0.. r -, Thank you for your payment • CUSTOMER COPY $