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Kiehl Semler - Ophira Cukierman I7oec - 0,, Ave DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D RECEIVED 1U1 I ANI I B E C H Office of the City Clerk FEB 14 2023 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: Semler Kiehl NAME OF LOBBYIST (Last) (First) (Middle Name) GSLA DESIGN,INC 17670 NW 78th Avenue,Suite 214 Miami Florida 33015 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-392-1016 kiehl@gsladesign.com LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Cukierman Ophira NAME OF PRINCIPAL (Last) (First) (Middle Name) • 1688 Property Owner,LLC 59 Greenacres Avenue Scarsdale NY 10583 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 917-860-0072 ocukierman@gmail.com PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS • REMEIgl 23 Gode Eitgitlia 2 82 hoil ra principal c2giv corporation partner 11,Cl?CAN GM Map appears em a lobbyist cm CAMP(gag ,Man special(4�__i�aA�r-flo d(op reimbursemen for appearance,f 1ii- L`timA,indirect,ay co in sent cbmgi gal.m3g(o4aroa position DE MG©lag ip , m ME§ bsection Mad]dt] ()Ward tbl 57ERWremistrationG If the principal is a Corporation, Partnership or Trust, the following information MUST be provided Lu pursuant to City Code Section 2-482(c): e9 • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(if none,write N/A): O. Cukierman m • 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. u_ LL O Page 1 of 5 DocVerify ID:052221 DO.6FA3-4CEA•943B-86725B5BCE99 Page 1 of 6 188725B58CE99 I ,III p(q�p3c 'I II I www.docverify.com. SJs"I(aiS1`=SS�� DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D 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 1709 Jefferson 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 W 0] 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): LL 0 Page 2 of 5 DocVerify ID: 052221 Do-6FA3-0CEA-943B-B8725B5BCE99 I Page 2 of 6 I 288725B5BCE99 wwwdo , ,III p�q�paRF 1��5C,I II I DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D 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 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 y�'esIhas7itibeenllenthaZlr2IonthTinceTthTlectedrfficial(s)[whom you provided campargn, consultingry seices s ni sworn wa 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 2 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— 0 within the past election cycle?If yes,please list the incumbent member(s)of the City Commission: N g w —Yes XNo: I yes, were you promised e r did you receive economic consideration in exchange for campaign consulting senvicest N r m m TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No. Amount Paid$ MCR# Date Paid a Lobbyist Registration Form,received and verified by: o F:\CLER\$ALL\aFORMS\L0BBYIIST'FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 N N Page 3 of 5 Docverify ID:052221 DO.6FA3-4CEA•943B-B872565BCE99 I Page 3 of 6 3B8725B5BCE99 I ,III Q(qZ �# 'I III www.docvenfy.com S'.fi'T' & . J DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D 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.1 Uocubigned by:II II Signature of Lobbyist: Cfiau,((bV' � itdu, SL4t4(Er Date 2/10/2023 9E2A485EA3AF4EC... 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. DocuSigne1d y:1 Signature of Lobbyist: I ttui(br IzitILL st,w,(tir Date 2/10/2023 —DoeuSigned by: 9E2A485EA3AF4EC... 2/13/2 02 3 Signature of Principal: ite `-023FE2F2E1034E2... 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 0 online notarization, • or1=1 online notarization, this 13 day of February ,.2023, by this 13 day of February ,20 23 by Kiehl Semler Ophira Cukierman_ NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X Personally K , x Personal Knrnnrn 4 .1 n �r: N Signature of Notary Public Signature of Notary Public Yeidy Montesino Yeidy Montesino Name of Notary,Typed, Printed or Stamped Name of Notary, Typed, Printed or Stamped W (NOTARY (NOTARY SEAL -- -'---- ----- ----------------------- -__.- . -_ m 1 Yeidy Montesino Perez 1 Yeidy Montesino Perez 0 03 1 Commission#HH 084273 1 Commission#HH 084273 I i Notary Public-State of Florida 1 Notary Public-State of Florida I m The term"lobbyi4 oy Commission Expires Jan 24,2025 1 tiAy Commission Expires Jan 24,2025 a 1 � rn ,m„s ,mssmvux:a rsr .«rewr�,sr„ um�v u�<:�r _ ,nern,,., Expert witnesses vn76 1 ���„..iy JVict li;IV, LA v;Z TNacialized information or C:r �'�.,,., ,..,,,.:,..,,,.,.-::..y,.,—., ,,,,,..,,,. .nc: m only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance, whether w direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of S not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for 7, the appearance. o Page 4 of 5 Docverify ID:052221D0.6FA3.4CEA-943B-B8725B5BCE99 I Page 4 of 6 I 4B8725B5BCE99 I ,III p�px p7C 'I II I www.docverify.com Qr'a�:6 DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D 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 CityClerk@miamibeachfl.gov Tel: 305.673.7411, Fax: 305.673.7254 NAME OF LOBBYIST: Kiehl Semler 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. 0 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 'm $500.00 pursuant to Section 2-482 of the Miami Beach City Code. • co DocuSigned by: "-6t4hir .it,�, St.,w►lter 2/10/2023 Signature of Lobb 9E2A485EA3AF4EC... Date C) U LL o F:ICLERI$ALL1aFORMS1LOBBYIST FORMSLLobbyist Registration Form Revised 03-11-20 REG.doc N Page 5 of 5 DocVerify ID:052221 DO.6FA3-4CEA•943B-B8725BSBCE99 Page 5 of 6 5B8725B5BCE99 imams"II I www.docverify.com DocuSign Envelope ID:9FF6DFED-3D99-442B-B5FF-3884597DEE5D Exhibit A: Disclosure of Interest 1688 Property owner, LLC • Ophira&Joram Cukierman(16.7%) 59 Greenacres Ave Scarsdale,NY 10583 . Melissa Eidelheit(16.7%) Bilsestr 6,Berlin 14193 Germany Alexandra Cukierman(16.7%) Hohmannstrabe 2 5i!I13 property 1688 14193 Berlin, 0 ner, „•, Germany Lea Waisberg(16.7%) FasanenstraBe 11,10623 Berlin Germany Benjamin Skoblo(16.7%) FasanenstraBe 11,10623 Berlin Germany Samuel Skoblo(16.7%) Fasanenstra8e 11,10623 Berlin Germany O W U m m m W U LL O DocVerify I052221D0-6FA3.4CEA-943B-B8725BSBCE99 Page 6 of 6 1 6B8725658CE99 ,III ", ,p�*s'I III www.docverify.com • docv'erify. co/ CCVER -' Lobbyist Registration Form - Kiehl Semler -.1709 Jefferson Ave.pdf DocVerify ID: 052221 D0-6FA3-4CEA-943B-B8725B5BCE99 Created: February 13, 2023 12:35:33 -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:Yeidy Montesino(ymp) February 13,2023 12:36:44-8:00[41FBCDFA95A4][74.220.90.117] ymontesino@brzoninglaw.com le 111111 • IIIIII IIIII IIIIII IIIII IIIII IIIII IIIII IIIII IIII IIIII IIIIII IIII IIII IIII • • • 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 DocVerwww.docveify lrDY0552221D0.6FA3.4CEA-943B.B8725858CE99 ,III •-J 'I III I Generated Cover Page] B8725B5BCE99 �. • x• r �'^y= i t u+ g f �g _ "w +a a < ? City Hail 1700 Convention Canter .0r. a� " x; Miami Beach ,ryFLy 33139 I � N C a LLI ,, as 305'S73-142O Welcome N._ "�; • ` a ��� ° 005954-0003 Adrian V. 02/14/2023 09:1OAM z �s • ,�,. r �` , ° MISCELLANEOUS N, Reference 1: MCR431284°� � �� P �r x° NCR OPEN (MCR) ii ' mk 2023 Item: MCR 1 0 850.00 �;, w' wit- NCR OPEN (MCR) 850.00 850.00 f ?irk/ --° ° `. '`�.�,. _.:� A:. , 850.00 ` La - „w � Subtotal !� 050.00 .,.•,-.„.•''':,;i3,5'.:',..,,,,,,,,;.!,k-ise, ,'..-;•;.--,-,-,„7,';::.-.1-t ,.-N-, >� r Y �� � .�{ sr a MASTERCARD A „ 7`Q u� � i , = Ref Number4279 / 28759 850.00 E, (�� ,„ , t o a A , Changa due 0.00 a :i ' .- as e T aS 5 > .A l �:, � z xxj Paid •by: TAYLOR K SEMLER fix, fC m rx ? © ac, f` L �� £ t„x£ i " �"` „3 r w, IlllilllllllIIIIIIIIIIIIIIIIllllllllllllllllllllllilllllllllll o ¢ � ,�1 , c� 2 � � , �, �, a „z Thank you for your payment of 01 a 7 °O LLB CUSTOMER COPY 4 Q �u. :,''k �� -<C ads �< azu u4N. ,tif fF g a s , % wti o, i