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Thomas Pagnott/Altos Del Mar, Ltd.m ,MIAMIBEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 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 Ordinance 2004-3435. NAME OF LOBBYIST: (Last) (First) (M.I.) Pagnotta Thomas BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) Altos Del Mar Ltd. 8500 S.W. 8th Street Miami FL 33144 TELEPHONE NUMBER: FAX NUMBER: EMAIL (305) 262-6533 Ext. 36 I. LOBBYIST RETAINED BY: NAME OF PRINCIPAL/CLIENT: Altos Del Mar, Ltd. BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 8500 S.W. 8th Street Suite 238 Miami FL 33144 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) (305) 262-6533 Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)J • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: AgUStln Herran • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Ste Attached ll. sPECIFIC LOBBY IssuE: Historic Preservation Board application for property located at 7833 Collins Avenue Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of IndividuallTitle B) Any Financial, Familial or Professional Relationship Mayor None Commissioners ' City Administration None Cit Attorne 's Office City Boards None City Committees MIADOCS 2392143 1 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A} LOBBYIST DISCLOSURE: (Required) None Other than normal COmpenSatlOn B) PRINCIPAL'S CISCLOSURE (OF LOBBYIST COMPENSATION): (Required) None other than normal compensation The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ^ Yes ©No: Are you lobbvinq 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 Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^ Yes D No: Are you lobbvinq on a pending application for a Development Agreement with the Citv or application for chanae of zoning map designation or change to the City's Future Land Use Map? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481 above) who only appears as a representative of anot-for-profit corporation or entity without special compensation er reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any item, shall register with the clerk as required by this section but, shall not be required to pay any registration fees. ^ Yes x^ No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON OCTOBER 15` EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CIT`~ CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSq.~'ION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT pL~ BE FILED E E~ THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTIN P OD. ~---~-.~ ~~ ~ ~ ~~ , nature of Lobbyist I do solemnly swear that a oft foregoing fat `due and c ect and that J have read or am familiar with the provisions contained in S tion -482 the Beach Ci ode and all reporting requirements. ----~ Signature of Lobbyisfi ~'~ -- _ -~ Signature of Principal/Client: _ _~ VI . LOBBYIST IDENTIFICATION: // -~j PRINCIPAL IDENTIFICATION: Produced ID Produced ID ~rm •~r~~ Pyg , ANAMARIA GUERRA-VERA F rm S~Y'P[;~•. ANAMARIA GUERRA-VERA Personally known (Cobb i~~`}• = MY COMMISSION # DD gtbn y kn wn (Print a~' ~~ = pAY COMMISSION # DD 451294 °`•~a EXPIRES: August 28, 2(H~- 'a~. ~` EXPIRES: August 213, 2Qt'•9 ry ;e of ~,;. Bonded Thru Notary Public Undervriters VII SIGNATURE ANDSTA P~~~1~T~E~`'ThmNota Public Underwriters '-.>,~~: oQ~ State of Florida, County of Miami-Dade Sworn to andsubs ~ibed,be#~re yne This lY da of )~' V , 20 State of Florida, County of Miami-Dade Sworn to and subscribe of re me This ~~ day of ~D ~ , 20~~ Signature of P c iVotary -State of Florida Notarizat of Lobbyist's signature Signatur of is Notary -State of Florida Notarization of Principal's signature "_'\ ~~, A CLERK'S USE ONL ~~ Annual Registration fee: es [ ] No Amount Paid ~ } MCR # ! Date Paid Lobbyist Registration Form received and verified by: Revised 12/08/04 MIADOCS 2392143 1 CITY OF MIAMI BEACH Lobbyist Registration - Disclosure of Interest for Altos Del Mar, Ltd. ENTITY % OF STOCK General Real Estate Corp. 19.80% Agustin Herran 100% 8500 SW 8th Street Miami, FL 33144 Pedrena Development Inc. 19.80% Manuel Herran 100% 8500 SW 8th Street Miami, FL 33144 James Dorsy 19.80% 8500 SW 8th Street Miami, FL 33144 Armando J. Guerra Revocable Trust 19.80% Sole Beneficiary: Armando J. Guerra Armando J. Guerra & Maria C. Guerra Revocable Trust Sole Beneficiary: Maria C. Guerra 8500 SW 8th Street Miami, FL 33144 Oscar Barbara 19.80% 8500 SW 8th Street Miami, FL 33144 MIADOCS 2392143 1