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Steven Avdakov - Shelborne Hotel Partners WC LP Co11 nS - DocuSign Envelope ID:B41CCD34-7FFB-40D2-B30B-AAB8A63D6737 RECEIVED MIAMI BEACH Office of the City Clerk FEB 12 2021 1700 Convention Center Drive CITY OF MIAM12 BEACH Miami Beach, FL 33139 OFFICE OF THE Ca) 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: Avdakov Steven NAME OF LOBBYIST (Last) (First) (Middle Name) Heritage Architectural Associates 2307 Chaplin Street Wheeling WV 26003 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (681)207-9975 savdakov@heritagearchitectural.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Leahy Ben NAME OF PRINCIPAL (Last) (First) (Middle Name) Shelborne Hotel Partners WC LP 1035 North Miami Avenue,Suite 201 Miami Florida 33136 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 324-4700 PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant to City Code Section 2-482(h)(1)(a): A principal of any corporation, partnership, or other entity who appears as a lobbyist on behalf of that entity,without special compensation or reimbursement for the appearance,whether direct, indirect,or contingent,to express support of or opposition to an item shall register with the Clerk as required by this subsection but shall not be required to pay any registration fees. 0 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): m m • NAME OF ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH LuCORPORATION,PARTNERSHIP OR TRUST(if none,write N/A): Please see the attached. LL LL Page 1 of 5 LD.inna'Rp,,,pse.+a 139-9A4E686469A0 Page 1 of 6 19A4EBB8469A0 �? DopuSign Envelope ID: B41CCD34-7FFB-40D2-B30B-AAB8A63D6737 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 &Planning Issues,including but not limited to the Historic Preservation Board, Design Review Board, Planning Board, Board of Adjustment,Land Use Development,City Commission, and any City Workshops or Committees,if necessary,relating to the property located at 1801 Collins Avenue in 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&Building Department None X Public Works &City Administration,PB,HPB, BOA None X DRB,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(if none,write N/A): None w 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): $22per hour m LL Page 2 of 5 LL DocVerify ID:F8B654FB-9507.4E9E-BE39.9A4EBeB469A0 Page 2 of 6 I 29A4EBBB469A0 'III R3� 1I III I www.docverify.com DocuSign Envelope ID:B41CCD34-7FFB-40D2-B30B-AAB8A63D6737 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 XNo: 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? i 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 XNo: 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 2-491(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. _Yes XNo: 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 x_No: 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 0 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 xNo: Have you provided campaign consulting services to an incumbent member of the City Commission o within the past election cycle?If yes, please list the incumbent member(s)of the City Commission: N 0 O Q m _Yes x No: If yes, were you promised or did you receive economic consideration in exchange for campaign m consulting services? a T m w TO BE COMPLETED BY CITY CLERK'S STAFF ONLY co w o_oc. LI —7 4 L w Annual Registration fee: [ ]Yes[ ]No Amount Paid$�J MCR# 1 C Date Paid C)L ( < m Lobbyist Registration Form received and verified by: in JS m F:\CLER\;ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 1, co co Page 3 of 5 I DocVerify ID:F8B654FB-9507-4E9E-BE39-9A4EBBB469A0 ^c KK-- ppryry����.. Page 3 of 6 39A4EB88469A0 'III _Kr S 11 II11 www.docverify.wm C Y_<'ti�' DocuSign Envelope ID:B41CCD34-7FFB-40D2-B30B-AAB8A63D6737 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: ••-------74.., -... Date 12/10/2020 VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of 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, by means of❑ physical presence by means of L physical presence or El online notarization, or 0 online notarization, ����e"" this day of ,20 `,_, by this 10 day of p c M'dr ,20 Zq by Steven Avdakov Ben Leahy NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION S Personally Known _ nally Known re — (_l - Signature of Notary Public Signature of otary Public N v�iScf wknscit( " Name of Notary,Typed, Printed or Stamped Name of Notary,Typed, Printed or Stamped (NOTARY SEAL) (NOTARY SEA AP ` DENISEN.WINSCHEI 03 W A ., -• M`(COMMISSION#G4 362560 a f• : € EXPIRES.Au9UESt5 202 Vrit!TS t_ M •',,: OR i,?,,' Bonded Thi, ut._ m 1 The term"lobbyist"specifically excludes the following persons: ��— w rn W Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who O only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether m 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. LL Page 4 of 5 cVerify ID.F8B654FB 9507-4E9E-8E39-9A4EBBB469A0 gggg^� + rDow docverify Com Page 4 of 6 49A4EBBB469A0 ,III gp11111 DocuSign Envelope ID:B41CCD34-7FFB-40D2-630B-AAB8A63D6737 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 COMPENSAT401gcEORIRG THE REPORTING PERIOD.' Sfq- tt Date 2/11/2021 Signature of Lobbyist: \-1944occ22830r4c4.. - 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 allnertitiguirements. Signature of Lobbyist: S a� Date 2/11/2021 `---BA4AFC2EooOGcF 4.. Signature of Principal: Date VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of 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, by means of 0 physical presence by means of 0 physical presence or IBJ online notarization, or 0 online notarization, this 11 day of February ,20 21, by this_day of ,20_, by Steven Avdakov Ben Leahy NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X Personall Personally Known A Signature of Notary Public Signature of Notary Public Diana Ramos N Name of Notary,Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped •Diana Ramos (NOTARY SEAL) Commission#GG 308355 m Notary Public-State of Florida My Commission Expires Apr 10,2023 1 Th: ng persons: co W 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. LL Page 4 of 5 DocVerify ID:F8B654FB-9507-4E9E-13539-9A4EBBB469A0 www docverify.com Page 5 of 6 59A4EBB6469A01 III Kin 'I II DocuSign Envelope ID:B41CCD34-7FFB-40D2-B3OB-AAB8A63D6737 MIAMI BEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeochfl.gov Office of the City Clerk Rafael E. Granada,City Clerk CityClerk@miamibeachfl.gov • Tel: 305.673.7411, Fax: 305.673.7254 • NAME OF LOBBYIST: Steven Avdakov 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 9. that issue, I shall immediately file a Notice of Withdrawal with the Office of the City Clerk. A 3) ANNUAL LOBBYIST REGISTRATION FEE 0 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. m / DocuSigned by: 2/11/2021 w L—EjA4A1C28830C4F4 Signature of Lobbyist Date F:CLER\SALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 03-11-20 REG.doc LL Page 5 of 5 --- ----- ----- —- - ___ _. ,- - pyo ' DocVdo ID:F8B654FB-95D7-0E9E-BE39-9A4EBB8469A0 Page 6 of 6 69A4EBBB469A0 Shelborne South Beach — Structure Chart There is no natural beneficial ,- owner with more than 5%in Shelborne Property King Street Real Estate GP II, LLC There is no natural beneficial (DE LLC) owner with more than 5%in Shelborne Property 100% Shelborne LLC (DE LLC) R. Kimel W. Kimel Shelborne 100% Associates USA LP 50% 50% (DE LP) Shelborne Holdings LLC (DE LLC) 5% „ 95% Westdale Properties CC Shelborne LLC 100% West Shelborne CC Shelborne GP [59.2%]; Investor LP(Canada LLC "Cedar LP" LP) (DE LLC) 0%;"Cedar GP" [40.8%]; "Westdale Shelborne Hotel Partner" Partners WC LP (DE LP) 100% CShelborne Property *Additional beneficial owners to be added to the extent additional separate elements is necessary. Miscellaneous Cash Receipt CITY OF MIAMI BEACH L . PNra7436 0 Cash 0 Credit Card 0 Check# FEB 2frl ' vo r T : rAl! 1 ‘F Receivedot 0. o n; Lkj \.). A.A IA; ' For t (THIS INFORMATION MU8T BE COMPLETED) Office of Finance Director By Account Number: Newer: Dept EXT: