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Scott Bakos/1825 Collins Avenue Owner, LLC°- MIAMI BEACH 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 encom'age the passage, defeat or tnoditication of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any city hoard 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 cotntnission, or a city board or committee. The tcnn specifically includes the principal as well as any employee engaged in lobbying activities. The term'`Lohhyists" has specitic exclusions. Please refer to Ordinance 2UU4-3435. NAME OF LOBBYIST: (Last) (First) (M.[.) Bakos Scott BUSINESS NAME ANU ADDRESS (Number and Street) (City) (State) ("Lip Code) Bermello Ajamil and Partners, Inc. One East Broward Boulevard, Suite 800 Ft. Lauderdale, FL 33301 TELEPHONE NUMBER: FAX NUMBER: EMAIL: (954) 627-5109 (954) 467-1116 sbakos@bermelloajamil.com I. LOBBYIST' KE'1'AINED BY: 1825 Collins Avenue Owner, LLC NAME OF PKINCJPAU('LIENT: 1825 Collins Avenue Owner, LLC 818 Greenwich Street New York, New York 10014 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 212-796-8400 212-796-8410 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 CHIF_.F OFFICER, PARTNER, OR BENEFICIARY: IUEN"11FY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST 1N SUCH CORPORATION, PARTNERSHIP OR'fRUS"I": I1. SPECIFIC' LOBBY ISSUE: Historic Preservation Board Application ]slue to be lobbied (Uescrihe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/riUe B) Any Financial, Familial or Professional Relationship ~~G'illiam I I. Cary, Director Design none Michael Belush, Senior Planner none Thomas R. Mooney, A1CP, Design and Preservation none Manager `~~ ~~~ ~ ' . IV. DISCLOSURE OF TERMS AND AMUl1NT5 OF LOBBYIST COMPENSATION (DISCLOSE V4'HETHER HOURLY, FLAT RATE OK OTHER): A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIS"I' COMPENSATION): (Required) $ The following information must be answered: I) Pursuant to Miami Beach City Code Section 2488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ^ Yes ~No Are you lobbying on a present or pending bid for goods equipment or services, or on a present or pending award for unndti e4ulpment pr 5CrViCe.7 2) PPursuant to Miami City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^ Yes Q'IVO Arc you lobbvm¢ nn a pendin¢ application fur a Development A2recment with the City or application for chance of znninQ map designation or chance to the City's Future Land Use Map'! 3) Pursuant to Miami Beach City Code 2-484 (h) A.tty person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481 above) who only appears as a representative of snot-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.. IV. SIGNATURE UNDER OATH: UN OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST SHALL, SUBMIT "f0 THE CITY CLERK A SIGNED STATEMENT UNDER OA"1'H, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE: CITY OF NHAAII BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE 1[AVE BEEN NO EXPENDITURES OR COMPENSATION llURING THE REPORTING PERIOD. of Lohbyist 1 do solemnly swear that all oY'the foregoing facts are true and correct attd that I have read or um familiar with the provisions contained in Section 2-482 of the Miami Beach Ci[y Code and all reporting ~quirements. Signature Signature V. LOBBYIST IDENTIFICATION:+ PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Lobbyist) Vl. SIGNATURE AND STAMP OF NOTARY StatcofFlorida,Coun of Miami-Dade ;~t~YPOe'a Yanet Godoy Sworn to and subscribed before me =x' ~~°=Commission #DD517622 This day of , 20_= doe` Expires; FEB. 13, 2010 ~~+ii~~jos`` WWW.AARONNOTARY.com Signature of Public Notary -State of Florida Notarization of Lobbyist's signature ^ ProduccdlD - Form of Identification '""""~ ,~ Yanet Godoy ~'Crsonally known (Principal) a ~ ~ :Commission #DD517fi22 ' ~,•~P,= Expires: FEB. 13, 2010 ~~~~++~n~o`'~` WWW,AARONNOTARYcom State of Florida, County of Miami-Dade Swop} n subsc i b f This / d ~~~~ J 20~ g Si pat e u is Notary -State of Florida Notariz• of Principal's signature OR CLERIk'S S~ ONLY G Annual Registration fee: ] Ycs ( ] No mount Paid MCR #;~~~-~j~ Date Paid_ Lobbyist Registration Form received and verified by ` F:\CLER1$ALLUv1AK1A-M\Lobbyist\LOBBYIST FO c ~` Revised 12/08/04 484519_Ldoc IV. DISCLOSiIRE OF TERMS AND AMOUN"1'S OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT FATE OR OTHER): A) LOBBYIST DISCLOSiJRE: B) PRINCIPAL'S DISCLOSUK t~+~~~ I IyK ~ ivy fCt~ The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2488 Entitled "Prohibited Campailm Contributions By Lobbyists On Procurement 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 a~mpensation 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 ~d No Are you reoresentioQ snot-for-Drofit corporation or entity without special comaensation or reimbursement? IV. SIGNATURE UNDER OATH: ON OCTOBER 1sT OF F.ACH YEAR, EACH LOBBYIST SHALL SURMTT TO THE CITY CLERK A SIGNED STATEMENT tINllF.R OATH, LISTING LOBBYING EXPENDI'1'ITRES, AS WELL AS COMPENSATION RECEIVED, IN TILE CITY OF MIAMI BF,ACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALI, BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITiJRES OR COMPENSATION DiIRING THE REPORTING PERIOD. r` ~. S i gn ature~i~IIt3byi st I do solemnly swear that all of a foregoing facts are vue and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City re requirements. Signature of Lobbyist: - Signature of PrineipaUClient: V. LOBBYIST IDENTIFICATION; PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification ~Pcrsonally known (Lobbyist) Vl. SIGNATURE AND State of Florida, County of Miat Sworn to and subscri be phis ~~day of ~~lP'%~Qk NOTARJ~NA t3. WII.ION ~~ ~~' ~ MY COMMISSION # DD 6266Ja *. ,r ~o EXPIRES: January 3, 20t 1 '~.~; a"r' ~.,', f3nnded Thru Not9ry Public Underwriters Notarization of Lobbyist's signature ^ Produced ID Form of Identification ~~""""•• Yanet Godoy S~tY PGe i ^ Personally known (Princi~.~ ~ Gn?COmmi5Sl0n #DD517622 9~'~~=Expires: FEB. 13 2010 •~errn*~~ www.AARONNOTARYcom State of Florida, County of Miami-Dade Sworn and subscribed before me This day of _ , 20___ Signature of Puhlic Notary -State of Florida Notarization of Principal's signature FOR CLERK'S fISE ONLY Annual Registration fee: [ ]Yes [ J No Amount Paid MCR # Date Paid Lobbyist Registration Form received and verified by: F:\CL.ER1$ALLIMARIA-M\Lobbyist\LOBBYIST FORM O5. doe Revised 12/08/04 484519_Ldoc 2) Pursuant to Miami City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues":