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Adrian Debkowski - Alexey Polyakov 5U o 6( 5, atlC Pr('VL DocuSign Envelope ID:C457169D-7E8F-4CAA-A8E5-4081BD9ED456 RECEIVED /V\I A/V\I B EAC H Office of the City Clerk DEC 09 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"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: Dabkowski Adrian NAME OF LOBBYIST (Last) (First) (Middle Name) Kimley-Horn&Associates 8201 Peters Road,Suite 2200 Plantation Florida 33324 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 954-535-5144 Adrian.Dabkowski@kimley-horn.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS • II. PRINCIPAL INFORMATION: Polyakov Alexev NAME OF PRINCIPAL (Last) (First) (Middle Name) Gaia USA LLC 801 S. Pointe Drive Miami Beach Florida 33139 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) • 732-277-8328 polyakov@metric-invest.com PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant m Man aggin 2-482(h)(1)(a):Q principal ataii s. .. . . partnership,l7i ( T CD a lobbyist m behalf ct2lI entity,sylaCIKO special compensation u=tlul'.mgtlur.3i134?pt)br,,.�.�-r_, .t t$ ill indirect,CP contingent ex.ress a(:20/o.Iosition(C an item shall register with the Clerk as required by this subsection but shall not be required to pay any registration fees. N ` 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): A. Polyakov 7_ • NAME OF ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH a CORPORATION, PARTNERSHIP OR TRUST(if none,write N/A): Please see the attached. c. w w Page 1 of 5 Dwww dower�co4E1 FBE-5900-4471-B112-73C876CF189D L Page 16 of 25 j 1673C876CF1 B9D 1DI g 'I III DocuSign Envelope ID:C457169D-7E8F-4CAA-A8E5-4081BD9ED456 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 801 S.Pointe Drive 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 a 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 C? 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): $355.00 per hour Page 2 of 5 DocVerify ID.6C4E1FBE-5900-1471-B112-73C876CF1 B9D C page 17 of 25 1773C876CF1B9D SDI 'I III www docveri fy.com • DocuSign Envelope ID:C457169D-7E8F-4CAA-A8E5-4081BD9ED456 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 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 XNo: If yes, has it been less than 12 months since the elected official(s)whom you provided campaign consulting services was sworn irn 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 a 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: Yes X No: If yes, were you promised or did you receive economic consideration in exchange for cam,ai•;n consulting services M TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid 0 Lobbyist Registration Form received and verified by: m F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 w Page 3 of 5 DocVerlfy ID:6C4E1FBE-5900-4471-B112-73C876C F1 B9D r Page 18 of 25 I 1873C876CF1 B9D 1 111I INEGISII www docvenfy.com DocuSign Envelope ID:C457169D-7E8F-4CAA-A8E5-4081BD9ED456 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 COM!ENSATION:DURING THE REPORTING PERIOD.' Signature of Lobbyist: QMa w k Oatlof�ewst i Date 12/05/2022 �b886lh38F083443... 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-andraticreporting requirements. Signature of Lobbyist: tafial , . allot,OWS4j,ous,gnedby: Date 12/05/2022 — —586B7F38F083443... Signature of Principal: Date 12Jn5/2022 08 cDPE6o4849... 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❑ physical presence or 1Konline notarization, or Ile online notarization, this day of 19/nar9m9 ,20 , by this_day of i'maMM ,20_, by Adrian Dabkowski Alexey Polyakov NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION x Personally Kno -- �Personally Kno ••-- 0 Signature of Notary Public Signature of Notary Public Diana Ramos Diana Ramos 0 Name of Notary,Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped Qiana Ramos , Iene Ramos / Commission#GG 308355 1 4 Commission#GG 308355 Notary Public-State of Florida 1' 1 Notary Public-State of Florida 1 Igy Commission Expires Apr 10,2023 J 1 ! s0:E: e :r 10,2023 ersons: Expel ..��I000GO YVI,.,Ni • Vvluc VIIly O1+10111111N, 1G-1 I�:al or other specialize ��.,��I�11V1�.,� «��IVlly N�:,��IOGI�IIyJ,any person who g 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 dower:6C4E1FBE-5900-4471-B112-73C876CF189D I Page 19 of 25 I 1973C876CF1B9D „I 'I III DocuSign Envelope ID:C457169D-7E8F-4CAA-A8E5-4081BD9ED456 MIAMI BEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.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: Adrian Dabkowski 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. DocuSigned by: M �Q�Yitain, �. OtalOWslci ll 12/05/2022 .,ocD7r3oro03443... Signature of Lobbyist Date 0 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 03-11-20 REG.doc Page 5 of 5 Dwwwdo er rycomElFBE•5900A471-6112-73a876CF169D Page20 of25 I 2073C876CF1B9D.jI F E iI'I III Legal structure as of December 8th 2022: Beneficiaries of The Hagen Beneficiaries of The Irida Trust: Trust: Mrs Maria Khazan(Milyayskaya) Mr Ivan Milyayskiy Shishkov Mr Ivan Milyayskiy Shishkov Mr Maximilian Milyayskiy Kharkov Ms Anna- Ms Sofia Milyayskaya Kharkova Maria Milyayskaya Shishkova Thamer Trustees Thamer Trustees Limited(as Trustee of Limited(as Trustee of The Hagen Trust) The Hagen Trust) (Cyprus) (Cyprus) Evgeny Kuzin Maxim Vlasov 75% 25% KV Holding Limited,DIFC,Dubai,UAE 60% 40% (ex Bulldozer Group Management Ltd) 100% Fundamental Group Holding Limited,DIFC,Dubai,UAE Metric Finance Enterprises Limited,BVI Bulldozer Group Holding Limited,UAE,DIFC 30% 70% Gala USA LLC,Delaware MBF `. ••` _, . ,_ - Customer Service Center a ▪- #a <:' 1755 Merdian Ave Suite 100 �, w Miami Beach 1 1 - ru , x , 4 33139 20 • • 'r. ,, r ° .. r ). .( ' Y a }, Welcome l.�4'� w• ,••a z • .`' 4 005840-0017 Ebani T. 12/09/2022 04:41PM { .+ ry, - '' ;.� �, . a� F k3�' sf MISCELLANEOUS `� "O 1 - Reference 1; MCR_430930 z f r ti 7 . MCR OPEN (NCR) 6.•= ,oY r Item; NCR r 1.00 1,400,00 _. j ', NCR OPEN (MCR) ,400.00 yy t- f y� C 1H :-.. P Y "Yd 1 M • W { �' ''' • 'Tr T! c c f 1,400.00 • ' f ` -•.re • Y-'' ' Subtotal 1,400.00 `. c i o Iota 1 1 x r ,400.00 �r � k 1▪ '' ° f ? CHECK , 350.00 ` ,e 4 °M Check Number00008300 • > A CHECK 350,00 Check Nuober00008301 350,00 ..°° CHECK., ` Check Number00008302 a • CHECK 350,00 - N + - Check Number00008259 ,� aQ n Change ,'� ''— . ' ' ..¢ tvr% : ' due 0.00 ` `� r°� • � ; ® Paid by: RERCOW RADELL FERNANDEZ & LARKIN �'; - fo E `� j ate, � fC � � 11��111111111111I11111��I11��1111IIIIIIIIIIIIIII��IIIIII��I��II ,v ▪ u o :+ Q. u. w' a g c'.E 9 L i-, e• , O 4 • • i#1100rH-_�-• IYN4OaYGIW emiw —.h°"b4'ta i - L p L f .rvVn .�... .,, e .. ,. ! y- =er .°▪ %' '.., ••• k�•� ,- - •r '." •-me,umaeuwsy«...,.,»-.....,....w.•....w,...„...�� aam' .. mnrrwuuapo+ _...e . . ails . 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