2024 Lobbyist Registration Form - 230 N Hibiscus DR (230 North Hibiscus Drive LLC) .23o N. F1�b�sGVS 1�c�tYe
-�u
� . � � Office of ihe City Clerk � j�]z¢
1700 ConveNion Center Drive
� Miami Beach, FL 33139 .
305.673 7411 � � �,
LOBBYIST REGISTRATION PORM
Lobbyist means all persons employed or retained, whether paid or not, by a pnncipal who seeks to encourage Me passage, defeat or
modification ot any ordinance, rewWtion, aclion or decision of any commissioner; any actioq decision, recommendation af the Ciry
Manager or any Ciry board or commitlee;or any action,decision or recommendatlon of any Ciry personnel durirg ihe time penotl of Me
entire decision-making process on such action, decision or rewmmendation that toreseeably will be heaM or reviewed by lhe City
Commission, or a City board or committee. The lerm specifiwlly indutles the prindpal as well as any employee engaged in lobbying
activities. The term "Lobbyis�"has specifc exclusions. Please refer to City Code Chap�er 2. ANcle VII, Division 3, enGtled"LobbyisLs,"
for additional informalion.
Instmctions: Please complete all seclions of this form and submit the completetl(oem,with ihe applicable tee,to lhe Office of 1he Ciry
Clerk. It you need more space ro wmplete an answer, use a sepaa�e sheet(s)of paper. If you have nothing to repoh in a particular
section, you must write 'none" or "n/a' in lhat sec0ort My cha�ge to any information originally filed, or any adtlitional Ciry
Commissioner or personnel wfio are also sought to be lobbied shall require that the lobbyist file an amendment ro Me 2gisira6an form.
The lobbyist has a continuing duty to supply information and amentl �he tortns fled tl�mughout �he period lha� Ihe lobbying occurs.
Separale regisiralion forms shall be required for each pnndpal represented on each specific issue.
I. LOBBYIST INFORMATION:
Moehring Robert Martin
NAME OF LOBBYI6T (Lesq (Flrst) (Mi001e Name)
DOMO Studio LLC 420 Lincoln Road, Suite 506 Miami Beach Florida 33139
LOBBVISTBUSINESSNAMEANDF�DRESS (NumberentlStreet) (CM1y) (Stete) (LpCOCe)
305-674-8031 305-984-3624 robert�domodesignstudio.com
LOBBYISTBUSMESSTELEPHONENUMBER CELWURTELEPHONENUMBER EMAILAD�RESS
II. PRINCIPAL INFORMATION:
230 North Hibiscus Drive LLC N�A N/A
NAME OF PRMQPAL (LesQ (Firsp (MitlEle Name)
230 North Hibiscus Drive LLC 8950 SW 74 CT, Suite 1901 Miami Florida 33156
PRINCIPALBUSINESSNAMEANDADDRESS (NumberentlStreet) (Ciry� (Steb� (ZipCotle)
N/A 617-803-0220 rafaelenriquegill�gmail.com
PRINCIPALBUSMESSTELEPHONENUMBER CELLULARTELEPHONENUMBER EMAILADORESS
PursueM to Cily COCe SecUon 2482(�)ppe): A pnnGpel of eny mrporetion. OeMershlp, or aCier enHly who eppears es e bbbyisl on behell W�he[
enlly,v�hout speciel mmpenselion a reimEursemeM M t�e eppeerence,whetln�Olrect,inElrect,or contlnpen[,la express support oi or opposXlon b
en i4em shell agisfer wilh Ue CIeM es repuirM�y I�is wbser.�m Oul s�aN rwt be rryulreE M pey eiry repistretion fees.
If the principal is a Corporation, Partnership or Trust, the following infortnation MUST be provided
pursuant to City Code Section 2d82�c�:
Ratael Gill Ramirez
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(i(none,w�ite N/A�:
. NAME OF ALL PERSONS HOLDING,DIRECTLV OR INDIRECTLY,A 5Ye OR MORE OWNERSMIP INTEREST IN SUCH
CORPORATION,PARTNERSMIP OR TRUST(ii none,write NIA�: $� attaChOd OXhibit5
Page 1 of 5 y�
rn1C LJ�
1 \�
III. ISSUE TO BE LOBBIED:
- Describe with as much detail as is prectical, 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 and 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
230 N Hibiscus Drive in Miami Beach, Florida
IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2382(a�(4), list the City Commissioner or Cily 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 ot Indivldual and Contractual Relationship(If yes,explain) �ES No
Title of Person to be Lobbied
Staff for the Plannin and Building De artment, None X
Public Works and City Administration None X
Planning Board, Historic Preservation Board None X
Board of Adjustment, Design Review Board None X
City Commission, and Mayor as necessary None X
N/A N/A N/A N/A
Pursuant to City Code Section 2182(g�, every registrent shall be required to state the e#ent 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
a earance of im ro ri if none write NIA :
None
N/A
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a
contingency fee is prohibited pursuant to City Code Sec. 2-085.3�:
$250/hr
Page 2 of 5
.
The following six(6)questions MUST be answeretl:
. 1) Pursuant to City Code Sedion 2d88.entitled'Prohibited Campaign Conlnbulions By Lobbyists On Procurement Issues"'.
Yes XNo: A V lObbv' 9 on o ese t oentll b'tl (of tl ea 'o nt itts or on e oresent or
p¢ tlI0U2W tl(OIO tl5 EOUIO ¢IItOlServlt2�
2) Pursuan[to City Code Sectian 2�90, entitletl 'PmhibiteC Campaign ConMbutions By Lobbyists On Real Estate Oevelopment
Issues"
Yes XNo: � u IobE ' a On ntllna 1ltetb f f e De I ment A ement Rh the C"N of BDoI"cation
for ch ae of z �na mao tl sianat r clw to l�e G'Ns Future Lantl Use Map�
3) Pursuant to Ciry Code Section 2�82�h�, any person (excepl lhose exempt from ihe definition of "lobbyist" as sel forth in
Section 2-081)who only appears as a represenfative of a �robfor-profit corporaEon or entity withoul special mmpensation or
reimbursement for the appearance,whether direct or indirecl lo express support of or opposition to any item,shall regis[er with
the ciry clerk as required by ihis section,but shall not be required to pay any registration fees.
Ves XNo: A You o ese11[ not f pfofit oo�8ti entiN itllout oeclal comosnsat'on of
reimbu�sement?
4) Pursuant to Ciry Code Section 2<81, Me lerm 'lobbyist" specifwlly ezclutles Ihe following persons'. Eryert witnesses who
provide onry scienMq technical or oMer spedalized information or testimony in public meetings: any person who only appears
as a representalive of a neighborhood associa4on wdhoul wmpensation or reimbursement for ihe appearance,whether tlirect,
indirec[or conlingent,to express support of or opposNon to any item;and any person who only appears as a representatne of
noMfoo-pro(t communiry based organ¢ation for ihe purpose of requesting a 92nt without special compensation or
reimbursement(or tha appearance.
_Yes�No: Are v u oro 'tlina onl uientifi techniwl or othe oecial"utl intormation� aocearina as a
reoresentaHve of neichborhootl ass -ation w'tt�out soe ' I comoensal�on or reim0ursement or
presenf a 8 not( f-0fo(1� E2 etl OM ii8ti f VI! o DOse f Guest na a al8nt wrthOU[
sce�ial como nsation or reimbursement?
5) Pursuanl to City Cotle Sec6on 2497�7), no campaigm m�sultant shall bbby the City Commission for a penod of 12 months
following ihe sweanng in of any elected oficial(s)hr whom Ihe campaigm m�suHant pmvitled campaign consulting services
wilhin the past elec�ion cytle-See SeGion 2-491 Por more infamation.
Ves XNo: H ou o �tletl ta ian t Itlna � es�o � Cumbe � member of tl1e GiN Commission
Wlth' the pa [ I Clion v I '+If Ve oleas I' t lhe in bent membellsl of the CM Commission:
N/A
_Yes�(No: It ves hss it been less than 12 moMhs si�e Me electetl officiallsl w�om vau orovi0etl wmoainn
onsultln services was swom in>
fi) Pursuanl to City Code Section 4482(a�(4)a., a 1o66yist who has within the past eleclion cycle provided campaign wnsulling
services to an incumbent member of Ne Ciy Gommission (which IobOying aclivity is not olherwise prohibitetl by Code section
2-491) shall disclose such particular service on hislher lobbyist regisVation form and shall�disclose such oartcular
b to I bb � [h C N C t bl' meel na.
VesX No: H v o �tletl o iu Itina � es t incumbent member of Me CiIV Commission
'th'nth o lel f CVtI IfVes ob flst[h intu be <me be131otth CftYCommisslon'
Nlf�.
Yes XNo: If es Yo oranisetl ditl vi cel onom consideralion 'n exchenae for camoaian
— — consWdnaservices?
TO BE COMPLEfED BV CITY CLERN'S STAFF ONLY�j 6
Annual Repistatlon fee: [ ]Ves[ ]No Amom[Paltl f�0/�0, MCR pLI��O Date Paltl3 2u �
LobOylst Rapis[ratlon Form recelvetl anE verlMaO Gy:A/"1 R�vi�eA 03/11/207A
Page 3 of 5
VI. SIGNATURES UNDER OATH:
- ON FEBRUARV 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED S7ATEMENT UNDER OATH LIS7ING LOBBYING EXPENDI7URES AS WELL AS COMPENSATION
RECEIVED FOR THE PRECEDING CALENDAR VEAR WI7H REGARD 70 THE SPECIFIC ISSUE ON WHICH THE
LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF 7HERE HAS BEEN NO
EXPENDITURE OR COMPE'N�SATION DURING THE REPORTING PERIOD.'
SignatureofLobbyist �[���� ��� �� Date d 3�«���1��
I do solemnly swear or affrm that all of Ihe foregoing facts. statements, and disclosures in this form are Irue and correct,
and that I have read or am familiar with Ihe provisions conlained in Chapter 2, Art. VII, Division 3, entitled "Lobbyisls" of
the Miami Beach City Code and all rep/orting requirements.
SignaWre of Lobbyist '�Y-��y Date C� 3/Z.7��'7���/
Signature of Principal: Date 3/25/2024
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of �1`oY i�-`1 State of Minnesota
Counry of: /�'�[a{'yl I—IMP��. County of: Wright
Sworn to (or affirme )and subscnbed before me, Sworn to(or affrmed)and subscribed before me,
by means of physical presence by means of 0 physical presence
or�—on'liR e notarization, � 1 or�online notarization,
Ihis•/ � day of �C�' �1 .20� by Ihis25thday o( MBfCh .2024 by
�G�-%3�itf �le�sl�m/�� Rafael Gill Ramirez
NAME OF LOBBVIST NAME OF PRINCIPAL
��roduced IDy� •Y� �'GGnS Pi X produced ID dfivBf'S flCen50
FORM OF IDENTIFlCATION FORM OF IDENTIFlCNTION
Pe rrdt Cnow _Personally Known
P.�l�.?�/
Si nature o Notary Public Sgnature of Notary Public
I ��� `�D�(V'e-� Patrick K Lindquist
Name of N Name of Notary, Typed, Prinled or Stamped
Notary Putfc Stace ol Florlaa
(NOTARY � �aure torres (NOTARY SEAL) $�w Ommi �
My LOTmI{SI011 MM N65GI PAIRIC Kl1ND0N5T
��„ Expres 9n9r3a]s `} �sorn
v:ms
� The lerm"IobbyisP'specifcally ezcludes ihe following persons: m.�.�.�.�.,.aa,,,,,�.,,mmm,,,,,�,,,,,,,,,,,,,oa
Expetl witnesses who provide only scientifq�echnical or other specialized information or testimony in public meetings; any pereon who
onty appears as a representative of a neighborhootl association without campensation or reimbursement for ihe appearence, whet�er
tlirect, indirect or contingent, to express support of or opposition ro any i�em; and any person w�o onty appears as a representative of
no4for-pro(t communiry based organization Por the purpose of requesting a grant without special compensation or reimbureement for
ihe appearance.
Page 4 of 5
� � " i '��� ' ^�� IBEA.CH
Ciy of Miemi Bwah, 1700 Convention Centxr Drive,Miami Beoch,Florida 33139,www.miomi6eochA.gov
OHice of the City Clerk
Rofoel E Gmnado, Cly Clerk CityClerk�miamibeachfl.gov
Te1: 305673J41I, Pox�. 305.673 7254
NAME OF LOBBYIST: ROBERT MOEHRING
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT
Pursuant to City Code Section 2�85(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 lo 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 Siatement or pay the
assessed fines after notifcation.
Any lobbyist, who fails to file the required Statement by April 30'" of each year, shall be
automatically suspended from lobbying until all fnes 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 Withdrewal 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 2-082 of the Miami Beach City Code.
��e��, <� C�'3/2�'/7'1`�
Sig�e of Lobbyist Date
F'\CLEP1fKLbFORMSLLCBBVIST FCRMSLMhys�Fyislre�r Fwm Rensdl 0]-i 1-30 PEG dcc
Page 5 of 5
Page 4 ot 8
� OWNER AFFIDAVIT FOR INDIVIDUAL OWNER
STATE OF
COUNN OF
�� _ , being first duly sworn, depose and certiFy as follows (l� I am ihe owner of
the pmperty that is the subject of this application. �2) This application and all information s�bmiBed in suppart of this
opplicatian, including sketches, data, ond other supplemenfary materials, are Ime and correct to Ihe best of my knowledge
and belieE �3� i a<knowledge and agree thaf, before this application may be publidy noticed and heord by a lond
development board, the application must be complete and all information submitled in support thereoF musf be acwrate. �4)
I also hereby aufhorize ihe City oF Mlami Beach fo enter my property for the sole purpose of posfing a Nofice of Public
Hearing on my property, as required by law. �5� I am responsible far remove this notice aker the dale of the hearing.
SIGNATURE
Swom b and subscribed beFore me ihis day of , 20_. T6e foregoing instrumenl was
ocknowledged before me by , who has produced as
identifimtion and/or is personally known to me and who did/did mt take an oath.
NOTARY SEAL OR STAMP
NOTARY PUBLIC
My Commissian Expires:
PRINT NAME
ALTERNATE OWNER AFFIDAVIT FOR CORPORATION PARTNERSMIP OR LIMITED LIABIl1TY COMPANY
STATE OF MinnesOt&
COUN7Y OF Wright
� aat�aicinftamtra: , being first duly sworn, depose ond certi(y as follows�. (1) I am the
Mana9erlBenaficialOwner (prinf fide� of �aoNonnHie'iscusoriveuc (print name of corporate eNiYy). �2� I am
authorized lo file this appliwtion on behalf of such entity. �3� This applimtion and all information submitted in support of this
application, including sketches, data, and other supplementary moterials, are true and correct to the best of my knowledge
and belieE �4� The mrporate entiy named herein is the owner of the property ihat is ihe sobject of thls application. (5� I
acknowledge and agree ihat, before this application may be publidy noticed and heard by a land development board, �he
opplicalion must be mmplete and all informotion submiMed in support ihereof must be atcumle. (6� I also hereby aufhorize
the City of Miaml Beach to enter my property for the sole purpose of posting a Notice of Public Heari�n my pmperty, as
required by law. (7) I am responsible for remave this notice aker the date o4 the hearing.
SIGNATURE
Swom to ond subscribed before me thls 12th day of �anuary , 20 24 . The foregoing insimment wos
acknowledged before me by Rafael Gill Ramirez , who has produced p855pOfI os
identifimtion and/or is personally known to me and who did/did not take on oath. /� �� �
__. ._ __� //����/
NOTARY SEAL OR STAMP � ,�E�`��° PP1"`" °epQp1$T
. <.y=
��`,6 mm, � NOTARYPUBl1C
My Commission Expires ��31/2025 __ ..o..�..---.�m—�—��•� Patrick K Lindquist
PRINT NAME
w o,a�om„�;u,�a�o p,o�;d�,iq o��a„i p��ls,����o�d,olsy��d���o iroo. ..,o,a,��d�loy��oor��b�o�n, ��op��4 na�o��...amm���H-
Paga 5 of 8
POWER OF ATfORNEY AFFIDAVIT
STATE OF MinneSOta
• COUNTYOF WrigM
I, _ Rafael Gill Ramirez � being firsl duly sworn, depose and cer�ify os Follows: �l� I am Ihe owner or
representalive of the owner of the real property Ihat is Ihe subject of Ihis applicalion. �2� I hareby aulFiorize
D�M� $tudl0 LLC b be my reprasentative bafore the Design Review g�rd. (3� I also hereby
authorize Ihe Cily of Miami Bea<h b enlar my property for Ihe sole purpose of posting a Nofice of Publi< Hearing on my
propery, as required by law. �4� I am responsible for remove this notice aNar ihe date of Ihe hearing. �
R f I G'll R � az — �
PRIM NAME (and Tifle, if appli�abk) SIGNATURE
Swom fo and subscribed before me this �2th day o( �anuary , po 24 . The foregoing inslrument was
acknowledged before me by Rafael Gill Ramirez , who has produced pasSpOff as
identiFication and/or is perwnally known to me and who did/did not lake an oalli. ���'�/
NOTARYSEALORSTAMP :1��� ° x�����oo��st _
��',� ��my �, 3 ao NOTARY PUBIIC
MyCommissionExpires: ��31/2025 __..,,.....a�.,..�..�„�.......,e.....�,a Pat�ickKLindquist
PRIM NAME
CONTRACT FOR PURCHASE
If Ihe applimnt is not Ihe owner oF Ihe properly, but Ihe applimnl is a party to a conhad lo purchase Iha properly, whelher
or not such contmct is contingenl on this applica�ion, the applicant shall list �he names of the conlwd purchasers babw,
induding any and all principa) oHicers, sl«kholders, beneficiaries or padners. If any oF Iha contat purchasers are
mrporalions, partnerships, limikd liabiliy companies, Irvsh, or olher corporale entilias, Ihe applicant shall fudher disclose
Iha identiy oF fhe individuals�s� (naNml persons) having the ulfimate ownership interasf in IFie enliy. If any confingency
<lausa or contmd farms involve additional individuals, corpomfions, partnerships, limiled liabiliy companies, kusls, or olhar
corporate enHties, lisl alI individuals and/or<orporale antities.
'�'y!1 f�l hh I-I'h'er c flr'vn ��
NAME DATE OF CONTRAR
NAME, ADDRESS AND OFPICE %OF STOCK
vama.,Hoe�:�P-smaesowesa.�aers va�wwarecce�aeawe �s �ro w.,re.msxxmnne�m.euc
ionw Oe.^e�o�Pd m �a Ha�y�LP
RalaeIGIIIRamirez�CallePMemtGomez1266Ao16BA5unionPa�eauav =W%ememeiPxnerdmenGaHeYirva
In the event oF any changes of ownership or changes in contwcts kr purchasa, subsequenl ro Ihe dale Ihal Ihis applica�ion if
filed, bul prior to the dafe of a final publi< hearing, Ifie applicanl shall file a supplemenfal discbsura of inleres�.
We arc mmml�o a wwrdr;��.eefle��poblk�m ond nky�,dl who:ns,�k,ona pby:�o���&a�r.�p(�d,nra«x��mun�ry.
Page 6 of 8
� DISCLOSURE Of INTEREST
CORPORATION, PARTNERSHIP OR LIMITED LIABILITY COMPANY
. If the property that is the subject of Ihe appllmtion is owned ar leased by a corporalion, partnership or limited liability
company, list ALL of the owners, shareholders, partners, managers and/or members, and the percenlage of ownershlp he�d
by each. If fhe owners <onsisl oF one or more <orporations, paRnerships, trush, parinershlps or olher corporafe entities, Ihe
applicaN shall further disdose ihe idenfity of ihe individual�s� �naturol persons� hoving the ultimate awnerthip interest in Ihe
eNiy.
230 North Hibiscus Drive LLC
NAME OF CORPORATE ENTIfY
NAME AND ADDRE55 % OF OWNERSHIP
PalmeraHoleingsLv-6inFL,89oWesiPeneerSt,VanwuveraC,CanaaaVSCtJ9 �owno.nero�zJouannweimmaeuc
The RGR Revocable Tmst-986 Sth Ave,FL 9,New Votic,New York, 100]5 WO%owneroi Pelmera rvoiemgs LP
Ra(aeIGillRamirez-GallePmfesorGomez1266,Ap�6B,Asuncion,Paraguay �roze.�=rpmwne.wmaacarm.rrysi
NAME OF CORPORATE ENTRY
NAME AND ADDRE55 %OF OWNERSHIP
If there are additional<orporate owners, list su<h owners, induding corpomte name and the name, address and perceniage
of ownership of each addllional owner, on a sepamte page.
wa o�e co,�,m�i��i ro� ohd�ne e�ua��p„bi�c se�:i�a�d sorery io ou�A,�ihe, wo�k,a��d uio�,m ov,adam,i,ov�w4 nai„�c mmm�mry.
n! "� � r� � \<�. ! VL/ \� � � '. ��._�Ur�
Ciry of Miami Beach 2 F 2024
. 1700 Convention Center Drive
Miami Beach, Florida 33139 � �! �'�!�CH
www.miamibeachfl.gov � �
City Clerk's Office
Tel: 305-673-7411
Fax: 305-673-7254 Omce Use Only
ANNUAL LOBBYIST REGISTRATION FORM
Name: I`C�''T" 1`���r{I2*h�� �
BusinessName: �CF�D ��L�[7lU LtL � Cttiv�C 11(4r�(7�C.i*-�RL � DiSiL-+1�
Address: �I�O CINr��� Ro�11/� �`7�- �0� MlA�`'11 (j�ACt� 1'(r 33(3y
�ce Telephone Number: 'JLS - ld7`� '�'U3 I
CellularTelephoneNumber: 3�5����S.f —�j(�,Z'�
Email Address: ��� h�"f �� {Ou��CS'�S��'�'C', «�
I/more fhan one lobbyist,please list:
�� ��r�a rt`,�o CcA�no - N���r�'��—
z�
3)
4)
5)
6)
7)
Submit this form to the Office of the City Clerk, along with a check for 5500 for each
lobbyist. Please make the check(s) payable to the City of Miami Beach.
For City Clerk's Office Use Only
MCRa: G/33��$
�i o" 3 —2$ — �-L/
Amount paid: / `�� � Date paid:
Processed by�1 \ Date:
FIGERRPlL1aFORMSLLOBBVISi FORMSVNNIIAL lOB9YI5T 0.EG6TMTION FO0.M reg.Eaa
City oi Miami Beach a '" � � ='
a D �� r'.� o ;; .� o D � � � 3
Clty Ilall 'm g x� � °' a � d �
1700 l;unveMian Center Ur. a � �+= o " _ _ ;, � � p m
Niamt Beach , R 33139 � � z 3 = p N 3 � T m
305-673-7420 � o� � o � o �� 3 m
Welcame � D - ;� n 3 0
3 A G T � N
('1
03/28/2024 04:54PM Adrian V. O d n z
006860-0014 z
, a = �
MISCEI.lANE0U5 � ^
Referance 1 : MCR433228 c � s »
MCR OPEN (MCR) m � �
2024 Item: MCR p � �
1 C $855.0000 3
MCR OPEN (MCR) $855.00 9
r
m
1
__'_________"' m
� � O
Su6total i855.00 0
Total 5�•00 �
VISA $855.00 ,�
Ref Number3174 / 115939
Chanee die 50.00 � ,,, Z
� o
Paid 6y: ROBERT M MOENRING 10
°. w
T W
�IINIIIIIIIIIIIIIIIIIIIIIIII�III�IIIIIIIIIIIIIIIIIIIIIuIIIIIIIIIIIII m n o � ��
X �
"i O
Thank vou fm� Your payment -
.. �
0
CUSIt1MER COPY O �
