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Jason Jones - Robert Balzebre \e-r l (6k11%`5 Avcd DocuSign Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 RECEIVED RECEIVED DEC 15 2022 /V\I A/\A I BEAC H Office of the City Clerk DEC 1 2022` ,�CF MIAMI BEACH 1700 Convention Center Drive FF E OF THE CITY CLERIC Miami Beach, FL 33139 CITY OF MIAMI BEGI� • 305.673.7411 OFFICF_OF THE CITY CLERK LOBBYIST REGISTRATION FORM r/ 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: Jones Jason NAME OF LOBBYIST (Last) (First) (Middle Name) Kimpton Surfcomber Hotel 1717 Collins Avenue Miami Beach Florida 33139 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786)346-3572 Jason.Jones@surfcomber.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Balzebre Robert NAME OF PRINCIPAL (Last) (First) (Middle Name) Chisholm Properties So Beach Inc. 1717 Collins Avenue Miami Beach Florida 33139 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 779-3808 robert@balzebre.com PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant to City Code 'eotion 2-482(it)(1i)(a): principal of any corporation,partnership, or other entity who appears as a lobbyist on behalf of that entity,dilinta special compensation CIF reimbursement for Mib-r-••• nrft�r��.dirfitgaCift indirect,i?contingent,inUg i td.p, Epo.•osition to an item shall register with the Clerk as required by his 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): N • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(if none,write N/A): Robert Balzebre 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): Please see the attached. W U W Qi Page 1 of 5 �Sv1^.-'� 3AC-E486-4780-AOD3-27726690041A Page 1 of6 127728690041A I MI .ellI I'III DocuSIgn Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 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&Permitting 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 1717 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 ,Land Use&Sustainability Committee 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 0 • 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): $0.00 per hour Page 2 of 5 DocVerify ID:EFBBE3AC-E486-4780-AOD3-27728690041A r Page 2 of 6 I 227728690041A J „I ,I fI I www docvenfy.com �Fig�Rl1 F DocuSign Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 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 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 X 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: -Yes X No: If vt"es�has7i7been7le' TthanZl2 hs'Tsince7thTlectedrofficialfglirvhom you provided campaign consulting services was sworn ins 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 X_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: N O N _Yes X No: If yes, were you Prom' ed or did xou receive economic consideration in exchange for campaign consulting servicesi TO BE COMPLETED BY CITY CLERK'S STAFF ONLY 0 t Annual Registration fee: f ]Yes[ ]No Amount Paid$ MCR# Date Paid th Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 Page 3 of 5 DocVerify ID:EFB13E3AC-E486-4780-AOD3-27728690041A Page 3 of 6 I 327728690041A I gnl erL?'Ecg ,l III www docverdy.com DocuSign Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR,_EACHLOBBYIST_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 COMPE-NSM DURING THE REPORTING PERIOD.1 Signature of Lobbyist: -7a,x8iaroyo,Nrl... Date 12/14/204 • 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 Coda-at orting requirements. Signature of Lobbyist: SI nedb : Date 12/14/2022 /J1Aa79lb40141-1... Ma �ekµ w /Q-I V Signature of Principal: ��tts�S�6v4(r4/Il�� Date 12/14/2022 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 El online notarization, or®online notarization, this 14 day of December ,2022, by this 14 day of December ,2022,by Jason Jones Robert Balzebre NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X Personally Know — x Personally Kno - - . Sgr.em ALnbt„O.RNdm Signature of Notary Public Signature of Notary Public Diana Ramos Diana Ramos Name of Notary, Typed,Printed or Stamped Name of Notary,Typed,Printed or Stamped I CODiana Ramos 1 Tana Ramos mmission#GG 308355 I 1 Commission#GG 308355 I1�otary Public State of Floridas. G gotary Public-State of Florida ley Commission Expires Apr 10,2023 1 icy Commission Expires Apr 10,2023 1 Th-I o Gig persons: o ,u.yEi..paIDnBt,,,:mN>¢T • w]Nm•TY�4 t,:,,:N GST ]T,NSI� Expel{wunC�arya'WI piuviu uiny acirw•iunc, Mann!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 DocVerify ID:EFBBE3AC-E486-4780-A0D3-27728690041A (— j ,II �I III v nvw.docverify corn j Page4of6 I 427728690041A I SAP! DocuSign Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 MIAMI BEACH 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 CityClerkt miamibeachfl.gov Tel:305.673.7411, Fax: 305.673.7254 NAME OF LOBBYIST: Jason Jones 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 $500.00 pursuant to Section 2-482 of the Miami Beach City Code. DocuSlpned by: 71A0197.AD141-1... 12/14/2022 Signature of Lobbyist Date P F:ICLERI$ALLWFORMSILOBBYIST FORMS\Lobbyist Registration Form Revised 03-11-20 REG.doc Page 5 of 5 Doc :do er comBE3AC-E486-4780•AOD3-27728690041A page5of 6 _�527728690041A ��BI RD7R..+T,I III 1 DocuSign Envelope ID:BA46FEF6-54BF-4224-9A8F-570DDE527735 DISCLOSURE OF OWNERSHIP INTEREST Robert P. Balzebre only natural individual with more than 5%interest Chisholm Properties South Beach Chart of Ownership Stock Number Certificate Holder of of Percentage No. Shares shares Status Ownership Robert P. 1 Balzebre 10 Outstanding 10.00% Balzebre 5 Family Trust 29 Outstanding 29.00% RPB Management 7 Trust 25 Outstanding 25.00% RPB Management 9 Trust 25 Outstanding 25.00% RPB Management 10 Trust 11 Outstanding 11.00% Total 100 100.00% • O O O N O 0 W tD L11 U W m m LL u Dwww.do ell fy EomBE3AC-E486-4780-A003-27728690041A Page of I 627728690041A� ,IIII I' docv'erify o°CVE9.' Lobbyist Registration Form -Jason Jones - executed.pdf DocVerify ID: EFBBE3AC-E486-4780-A0D3-277286.90041A Created: December 14, 2022 10:44:23 -8:00 Pages: 6 Electronic Notary: Yes/ State: FL This document is a DocVerify VeriVaulted protected version of the document named above.It was created by a notary or on the behalf of a notary,and it is also a DocVerify E-Sign document,which means this document was created for the purposes of Electronic Signatures and/or Electronic Notary.Tampered or altered documents can be easily verified and validated with the DocVerify veriCheck system. Go to www.docverify.com at any time to verify or validate the authenticity and integrity of this or any other DocVerify VeriVaulted document. E-Signature Summary E.-Signature Notary:Diana Ramos(DR) December 14,2022 10:45:44-8:00[331464519688][74.220.90.117] dramos@brzoninglaw.com Ii , r . I5'IJI I111111111111111111111111111111111111liii!11111 I11111111111111liii liii DocVerify documents cannot be altered or tampered with in any way once they are protected by the DocVerify VeriVault System.Best viewed with Adobe Reader or Adobe Acrobat. All visible electronic signatures contained in this document are symbolic representations of the persons signature,and not intended to be an accurate depiction of the persons actual signature as defined by various Acts and/or Laws. • I Doc do er:EoBBE3AC-E486-4780-A0D3-27728690041A 1111 ani H LGenerated Cover Pagel 2772869f1041A •'IIF��TiY�7�S.. 6 »¢fir.. --, t • , + , �.. } - .y,., L ..m. . -z MBF i ` ' _, ,.,• _ , ) City Hall , . 1700 Convention Center Dr.. i"' ''' ° x Miami Beach , FL 33139 { N -. �, 305-673-7420 ._M 7 ✓`xA • o. Welcome s., y- » ,: .,t _ 005855-0002 Adrian V, 12/16/2022 09:47AM ° • • • " MISCELLANEOUS `` � o • Reference 1 : MCR430935 i,{ ,'.< , 1 f MCR OPEN (NCR) I. ' ` m 1 1,200,00 : MCR I I' K' c'a ^. r fa a a ,,,= ▪ ,� MCR OPEN (MCR) 1,200,00 ,. . ` _ ` „ , r 1 Subtotal 1►200.00 `‘ : t ▪ >' 'Total 1,200.00 i, ") a , , ` n ,a ,". " O 3 L..,\ -- .' CHECK 850.00 f' C c� ., Check Number00008088 ''- ^ m ` CHECK 350.00 Q. �-• ' �� Check Number00008316 C� f 1 'ky ; c> u _ ;'o • ; N ,> '-- 1 Change due 0.00 m - ` • 1� Paid by: BERCOW RADELL FERBABDEZ & LARKIN t ,. e L A n C . "O .Q y Vo N El d� IIIIIIIIIIIIIIIIIIIIIIIIIOIIIIIIIIII. aa tAtilJAWN ma ' 131.30.1 Q E--- 8 ; Qa . , r•EiQgll'a�MnQ/....ur.re.r,.w.....r.....r...o pYlW O WWII • C anaauw,auw NC l0431 M.LWAdLa W aAl.iSSIZIPf6W 496 q. • OM - ...n...a.a.Ina:»....._.r...,.�...—..�......«.wnw * uHaoo A � ISM R1 ga1WpRSYa1 .,:ia, lrZ.,._�I !' • • Thank you for your payment CUSTOMER COPY