Kent Harrison Robbins - Mitch Novick Myk ovts-lay
RECEIVED
Office of the City Clerk JUL 12 2022
1700 Convention Center Drive
Miami Beach, FL 33139 CITY OF MIAMI BEACH
305.673.7411 OFFICE OF THE CITY CLERK
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"Lobbyist"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:
ROBBINS, KENT HARRISON
NAME OF LOBBYIST (Last) (First) (Middle Name)
THE LAW OFFICES OF KENT HARRISON ROBBINS, P.A.,242 NE 27TH ST, MIAMI, FLORIDA 33137
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 532-0500 (305)632-1770 khr@khrlawoffices.com
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
MITCH NOVICK
NAME OF PRINCIPAL (Last) (First) (Middle Name)
901 COLLINS AVENUE, PH, MIAMI BEACH, FL 33139 fist . 'g`!'tf ( '/41
PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Stre Ctt State (ZipC e)
(305) 532-0958 SHERBROOKE2001@HOTMAIL. OM
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
art item shall register with the Clerk as required by this subsection but shalt nut be required to pay any registration fees.
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): N/A
• 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): N/A
Page 1 of 5
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.
LEGAL REPRESENTATION OF MITCH NOVICK, CONCERNING THE COLLINS AVENUE AND OCEAN DRIVE
MXE OVERLAY ORDINANCE AND RELATED COMPREHENSIVE PLAN AMENDMENT AND LDR AMENDMENT
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
HISTORIC PRESERVATION BOARD NONE f X
NNING BOARD NONE Y
DESIGN REVIEW BOARD NONE X
G D T NONE X
CITY ATTORNEYS OFFICE NONE X
NONE X----
MAYOR'S OFFICE NONE X
NONE— X
CITY COMMISSION 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
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):
$645/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 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?
2) Pursuant to City Code Section 2-490, entitled 'Prohibited Campaign Contributions By Lobbyists On Real Estate Development
Issues`:
_Yes XNo: 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, ,No: 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:
N/A
Yes No: It yes. has it been less than 12 months since the elected officialisl 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 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:
N/A
Yes_No: It 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: [ ]Yes[ j No Amount Paid 535O•c MCR# 1130 03 4 _v Date Paid 0 7- `-
Lobbyist Registration Form received and verified by: I
F7NCIER+. .4!. • Revised 03/11/2020
Page 3 of 5
. . •
VI SIGNATURES UNDER OATH
ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMir 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 URING THE REPORTING PERICD '
Signature Of Lobbyist: 0.4040, _ Date__
4....
I do solemnly swear or affirm tnat aft of tne foregoing ta,„;, ,Taterners and disclosures in rts ic;rn af-t or :lf-v %,.,/,-- ,.
and that I have read or am familiar with tne provisions aireri •r' Cr4oter 2, An Vli Divisior :,,, entitiPri Lohn,,!sts • .
the Miami Beach City Code and at r o g reduirernenl
Signature oi Lobbyist Da:e 7//4.12
._ .. ....... .._ _ ... . _ ._.___
... ,
Signature of Principal. ,,= • _..;v:.•:- .
• .0..- .
VII. NOTARY SIGNATURE AND SEAL:
LOBEP:IST- ,
, PRINCIPAL
State of ft-Oft-1 14 6 Stay:r-,1 ___ ft-Z NIA
County of. Poi 1 rtiltiklift6 Courri of
Sworn to(or affirmed,and subscribed befrire me :. Sworn to or aft-meal and SubsCribea before me
by means of El physical presence ! by means of!::: physical presence
or r.1.*..on.kmnotarizationt. n or iT,Dio notanzattoa„
this IV—day of • ve,...U.Yji .17.-. this V1ZTay of ,.7..3kAtr71 ________ 201:Zoiv
2.
latte4 (g5* -kir‘311\IS , Mt 10A 140/11__C46-
E OF LO8BYIST - floor or PRI PAi.
_Produced ID , Produced ID _
FORM OF!DENTIFICATION FORM OF 10EtsiT1FICAT ION
IPersonally 4jipp
di' _.....
Aar
5,grature 46.74." Signature ot : c
11111P"C
.:._. -ep____6__
-
Name of Notary Typed Printed or Stamped Name df Notary. 1-..ir.f-i! 'i:', i-tc,:t. ,-; -7,t r.r.,.,,,
.........
(NOTARY SEA .kliS,:iVjs*. ERNESTO REYES
i NOT 411 4,-•& ERNESTO REYES 0
;A...... Notary Public-State of Florida 1 :11-1-•'''.7" Notary Pubiic-State of Florida )
i:3,,,./51; Commission 4'I-IN 099492 .,11:' Commission 2 H1-1099992 ,
4 \71:91,F,!5/ My Comm.Expires Mar 21.2025 I \:fo.:o!....1 My Comm.Expires Mar 21.2025
through National Notary Assn. Boridee through National Notary Assn.
- The term"lobbyist" stimPf•Itio"mmulywo."01.9111"1Pw.11.4".
Expert witnesses who provide oniy scientific technical of otr-,c ,:iei-iaiized information or testimony In public rIleettnos.any person whr,
only appears as a representative ot a neignixittood associal, -vithour compensation or fetrnburf.emerit for the appearance. wnerner
direct. indirect or contingent to express support of or oppos i..”- it, any Item and any person who only appears as a representative 0'
not-for-profit community based organizabc•41 for the purpose il ri,,toesting a grant without special compensation oc IsNint:sUrSernent for
the appearance
Page 4 of 5
RECEIVED
Office of the City Clerk JUL 12 2022
1700 Convention Center Drive
Miami Beach, FL 33139 CITY OF MIAMI BEACH
305.673.7411 OFFICE OF THE CITY CLERK
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 "Lobbyist"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:
ROBBINS, KENT HARRISON
NAME OF LOBBYIST (Last) (First) (Middle Name)
THE LAW OFFICES OF KENT HARRISON ROBBINS, P.A., 242 NE 27TH ST, MIAMI, FLORIDA 33137
LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305) 532-0500 (305)632-1770 khr@khrlawoffices.com
LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS
II. PRINCIPAL INFORMATION:
MITCH NOVICK
NAME OF PRINCIPAL (Last) (First) (Middle Name)
901 COLLINS AVENUE, PH, MIAMI BEACH, FL 3313910pule►'di� t PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Str Cit ) V4)
) (Zip Cl:octe)
( Y ( ( P
(305) 532-0958 SHERBROOKE2001@HOTMAIL. OM
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.
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): N/A
• 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): N/A
Page 1 of 5
Ill. 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.
LEGAL REPRESENTATION OF MITCH NOVICK, CONCERNING THE COLLINS AVENUE AND OCEAN DRIVE
MXE OVERLAY ORDINANCE AND RELATED COMPREHENSIVE PLAN AMENDMENT AND LDR AMENDMENT
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
HISTORIC PRESERVATION BOARD NONE X
-NAN I G-BOARD NONE - X
DESIGN REVIEW BOARD NONE X
ZONING BOARD OF ADJUSTMENT NONE X
CITY ATTORNEYS OFFICE NONE X
PLANNING STAFF NONE X
MAYOR'S OFFICE NONE X
CITI MANAGER S Of-h t NONE —
CITY COMMISSION 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 ------------
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):
$645/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 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?
2) Pursuant to City Code Section 2-490. entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development
Issues`:
_Yes,xNo: Are you lobbying on a pending appiication 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:
N/A
Yes_No: It yes. has it been less than 12 months since the elected officia1sl 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 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:
N/A
Yes No:• 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: [ j Yes[ j No Amount Paid$ MCR#— Date Paid
Lobbyist Registration Form received and verified by:
' `•CttP.,cnit •aFul"- Revised 03/11/2020
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 j,QBBYING 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 URING THE REPORTING PERIOD:
gooki:rs /44..
nature of Loobyist: Date _ —lb-Z/12- .
I do solemnly swear or affirm that all of the foregoing ra(,t- -,!?4*:rie,Iii aria alscto,sures in r is t:.):•r, zv.- , ,- .,' " : .
and that I have read or am familiar N,4' the provisions contarec '1 C,,aoter 2, Art V Div,stor I'L enlit,c _'-,1-,1-,,St
the Miami Beach City Code and ai .. requirement
: . ifelf4.
Signature of Lobbyist , garesr ,'- 7/ getrz _
. . .
Signature of Principar .
•
VII. NOTARY SIGNATURE AND SEAL'
LOBE31','IST- . , PRINCIPAL
,
St - ' fLorl t) state of ftA P-AviA _
County of Atitik&thIlltizt County of. NI ItMl ..bovi 6
i
Sworn to tor affirmed, and subscribed before me Sworn to tor affirmed, and subsoripeo before me
by means of 0 physical presence I Oy means of :7. physical presence
or 1_ oniwnotarization of '.:(De!notanzatic___,n
this i day of _j__NItAk ____ 4k-l _ _____ __ 201241v
.._.
Y-Wr 1411-04450N i10 _511\LS ; • 11/44,110ick ij04‘CV--
NAME OF LOBBYIST NAME'OF PRINCIPA,
Produced ID l''()duce° ID
--
FORM OF IDENTIFICATION FORM OF ICENTIFICPkT ION
1/Personally g 0 ri V . •
—
Signature SrilirlimLic .-.-,",gnatwe
Name of Notary Typed, Printed or Star.. Na
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Name -rf Nclary ,y-ried ortntP.,,ct or SI Ilpeti
mhaamdammr.dwidaftakah. 11.0.......0+0+0.4116+m'a*-11".
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NOTARY SE14),43 ,1 ERNEST°REYES • ,,e)e.... •
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. , ,k..•., otary Publk-State or Flonda k NOT 1 ,. . ,..4.:....\ Notary Public-State of Flonda
A Commission 2:HH 099992 r• IW. :' Commission a HH 099992 6
1 \ oF nF.''' my Comm.Expires ear 21.2025 P ' ..-.'•!0,r,.../ my Comm.Expires Mar 21.2025
i- -5ortee through National Notary Assn. I Sanded through National Notary Assn.
'The term"lobbyisr spleNatTrrrer",^-1."S1llrurwir.r7TUPWi., orioseiworeerweiworiermaxespie.
Expert witnesses who provide only sCaentific ter_hnic,at cu QuIr; ,.;;e,-,a;zit..-1,nforrnatioc or testimony in public meetings,early person wise
only appears as a representative of a neighborhood assooat. .,..1,-,o ii compensation or reimbursement for the appearance. whether
direct, indirect or coltingent to express support of or oppos ti. • ". 3, i tern and any person who only appears as a lepresentaove o!
not-forprotit community based organizatioo for the polhose • i .-;,.,.-Aiing a grant without special r,0rnpensation or teirnbur5ernent for
the appearance
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1700 Convention Center Dr. � �� ,: le; =
Miami Beach , FL 33139ii
305-673-7420 ` c ,_ ..,
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005579-0010 Adrian V 07/12/2022 11:25AM r,
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MISCELLANEOUS 1' m - 73
Reference 1: MCR430054 (,. m'J ii 0
2022 Item: MCR
MCR OPEN (MCR) 350.00 1 .- la
L.
350.00 -,...1 .J
Subtotal 350.00 ' 11( `1,
Total 350.00 �,
MASTERCARD 350.00 ~ . ! '
Ref Number5774 / 77316P -
Change due 0.00 '`
Paid by: MITCHELL S NOVICK
Thank you for your payment �"� w
CUSTOMER COPY c 5.1)
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