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Allan T. Shulman/Xenia 2206 LLCm 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) Shulman & Associates 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@shulman-design.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: Xenia 2206, LLC NAME OF PRINCIPAL/CLIENT: 119 Washington Avenue Suite 101 Miami Beach FL 33139 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (786) 443-6395 dg@nereo.it 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: Daniel Goldstein • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Renzo Rangoni, Renato Rangoni II. SPECIFIC LOBBY ISSUE: Redevelopment of 2206 Park Avenue and 427 22 Street - COA, Variance Approvals Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship Planning Dept., HPB, BOA, Planning Board, City Commission * None .:~t:E.~~ „s .. ._ * Unless an issue is legislative in nature, HPB, BOA, Planning Board, and City Commission members are not Lobbied outside of a public hearing setting. 1V. UlDI.LV,UKt Vt ItKMJAryUAMVUry1J Vt LVtftiTl,I I:VMF~t1YJA11VIV (U1,l:LVDt Wr1tIr1CK /'1VUKL7~ fLAT RATE OR OTHERr ~j /~ ~ /~ A) LOBBYIST DISCLOSURE: (Required) $ ~ `~ O' ~ y Y ~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 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 lobbyina on a present or vending bid for goods eauioment or services or on a ~rP~nt or pending award for goods eauioment 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 lobbyina on a pgnding application for a Development Agreement with the Citv or ~p,.plication for chance of zoning man designation or change to the Citv's Future Land Use Man? 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 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.. ^ Yes X No• Are you representing anot-for-vrofit corporation or entity without special comvensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT 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. Signature of Lobbyist 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. ~ ,C~ - ~~~/1i~7~'~- Signature of Lobbyist: / °'~/ cf N O ti ~ ~ ~ N oSignature of Principal/Client: O pM v o ~ Q N ~1/I. LOBBYIST IDENTIFICATION: ~~ o ~.~ o ~ ~ ^ Produced ID ~' ~ •~ '~ Form of Identification cn N y , , ~. ~ V w 7 Personally known (Lobbyist) ~- ~ 'WII. SIGNATURE AND STAMP OF NOTARY: H '~ z J p'State of Florida, County of Miami-Dade SworR~o a subscribed of re me This <h day of 20~ Signature of Publi Notary -State of Florida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Principal) State of Florida, County of Miami-Dade Sworn and subscribed before me This day of , 20_ Signature of Public Notary -State of Florida Notarization of Principal's signature FOR CLERK'S USE ONLY p/ ~ ~ ~ ~ ~ Annual Registration fee: [ ]Yes [ ] No Amount Paid ~~ MCR # ~ l~/ Date Paid 1~ -"ice ©~ Form received and verified by: ~ Entered By: '' IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, fLAT RATE OR OTHERr A) LOBBYIST DISCLOSURE: (Required) $ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 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 lobbying on a present or pending bid for goods, eguiument or services, or on a present or vending award for goods, egui~ment 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 lobbying on a vending auplication for a Development Agreement with the Citv or a~~lication for change of zoning man designation or change to the City's Future Land Use Ma°? 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 rearesenting anot-for-profit coruoration or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT 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. Signature of Lobbyist 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/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to and subscribed before me This day of , 20_ Signature of Public Notary -State of Florida Notarization of Lobbyist's signature C Produced ID Form a ifi t' n // ,.~`;; `~ Pie,,, 09CAR M BARRAMEDA [Personally known (Pr' `~: Notary Public -Stab of Fbrida "sN, . • = MY Coirrrnistlon ExpNas FaD 22, 2011 '; ~ ~` Commission ii! DO 638291 Bonded Through Wetloryl nw„y Assn. State of Florida, County o i i- a e Sworn and subscribed before me This ~?~Lday ~~, 2 Signature of Public tary .State of Florida Notarization of Principal's signature FOR CLERK'S USE ONLY Annual Registration fee: [ `~] Yes [ ] No Amount Paid 6 -~ MCR # ~/ ~~ Date Paid ~ ~ ~ D Lobbyist Registration Form received and verified by: Entered By: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYI57 fORM OS.doc Revised 12/08/04 Lity of Miami beach, '.~'C:, .: _ _ :- ~.~- _.. ~ ~,~, .. ~ _~,~ °3~..wv.~ . ~~ °' `~cw _, ram„ ~-•,~ -- ~-~r_'~.~-~I ~>ec~ .>l.acw ul~~~ ~~~~~>~~ ~a~~: ~-1 la n ~~ ~ understcnd tl;,o« ra eater than C7CtQber 1 ~Qf~ath Rear, I must file the following forms, „;rsuant io Section ~-~85 of ti7e Miame F~each C'~f Cade, wain the City Clerk's ~~;ce ror al. a'~ive lobbying issues. ~ ! obbyist Expenaiture Fc-m 2~ Disclosure Form Failure to file }here farms an a timely basis wil'; result it my Hume being transmitted to fhe Nr~ar~i-Dade Coun±y Commission an chcs ar:c far cads vi~lcian e~,~aluation. !r: o::diiion, ante or issue ! ~ave regis'ered to 'obby on has been resolved, I cm required J, mmedictely notify tl?e City Clerl~'s Office of lnb`~;yist withdrUwo n wri~ir~g. . ~ -~; , r :~ ~~ } ~~gna~G.e: VQd~«.