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Allan Shulman/Collins Corner, LLC~ 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 Ordnance 2004-3435. Shulman Allan T• NAME OF LOBBYIST: (Last) (First) (M.I) Allan T. Shulman Architect, P.A. 100 NE 36 Street Miami, Florida 33137 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (305) 438-0609 (305) 438-0170 allan@shulmanarchitect.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Collins Corner LLC NAME OF PRINCIPAL/CLIENT: 381 Park Avenue South Suite 1420 New York NY 10016 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (212) 684-7079 ext 19 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Eric Margules IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Redevelopment of 1201, 1221, and 1225 Collins Avenue Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title I B) Any Financial, Familial or Professional Relationship Planning Dept., HPB, BOA, Planning Board, City Commission None IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHERt Q A) LOBBYIST DISCLOSURE: (Required) _$ ~ Q 1 ©~~ 4' B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $ ~ D , OO~ 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 X No: Are you lobbvina on a present or pendina bid for aoods, equipment or services, or on a present or pendina award for aoods, equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes X No: Are you lobbvina on a pendina application for a Development Agreement with the City or application for chanae of zoning map designation or chanae to the Citv's Future Land Use Mau? 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 or 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 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMTT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. j~l /~-~ cam/ ~-/~~'~ Signature of Lobbyist 'zs ~ ~_c ~s:~~ ~~~ O !O >` X Zfn~ W . t > ~ 3~ . s~ I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/C VI. LOBBYIST IDENTIFICATION: Produced ID Form of Identification Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: \i State of to ida, Cou i mi- de Sw sc be Thi day , Sj~atGre of Public Notary -State of Florida otarization of Lobbyist's signatureof Lobbyist's signature Annual Registration fee: [~'] Yes [ ] No Signature of Pud`IicilVotary - State~t3fFloTlfl'a ~!ec Notarizatio of Principal's signature ~ ~~ ~ ~ N (~ *~ O N ~Z~V ~ o~ c~ ~~~~~ }}~~ ~'~° JCn~G x 6~ ~ ~ '~ ~ ,n ~ r ~C~.w ~a ~, is.v. _} ~~ U p~ ~ `: C~ FOR CLERK'S USE ONLY Amount Paid ~ S - MCR # ~~~ / Date Paid ~ ~-3 ~ ( ' Lobbyist Registration Form received and verified by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc PRINCIPAL IDENTIFICATION: Produced ID Form of Identification 'Personally known (Principal) Sf~te.nf~rada;-~-ettntq-of-Miami-Dade Sworn and subscribed before me This,~~day of Oc-~~~ c~~ , 20 ~ Entered By: Revised 12/08/04