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Ira Sussman - S.F. Land, LLC t, 565 C>Dl ;.,s 41,,e) X DocuSign Envelope ID:9F0829D3-A52E-4233-BBA8-E527DED577FB EcEdvED M I AM I BEACH Office of the City Clerk JUN 17 2022 1700 Convention Center Drive Miami Beach,FL 33139 ®PPi e��MI AMI s . C17y C�RK 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 City Code Chapter 2,Article VII, Division 3, entitled"Lobbyists," for additional information. Instructions: Please complete all sections of this form and submit the completed form,with the applicable fee, to the Office of the City Clerk. If you need more space to complete an answer, use a separate sheet(s)of paper. If you have nothing to report in a particular section, you must write "none" or "n/a" in that section. Any change to any information originally filed, or any additional City Commissioner or personnel who are also sought to be lobbied shall require that the lobbyist file an amendment to the registration form. The lobbyist has a continuing duty to supply information and amend the forms filed throughout the period that the lobbying occurs. Separate registration forms shall be required for each principal represented on each specific issue. I. LOBBYIST INFORMATION: Sussman Ira NAME OF LOBBYIST (Last) (First) (Middle Name) S.F. Land, LLC 6565 Collins Avenue Miami Beach FL 33141 LOBBYIST BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-866-8855 irasussman@the-beach.net LOBBYIST BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS II. PRINCIPAL INFORMATION: Sussman Ira NAME OF PRINCIPAL (Last) (First) (Middle Name) S.F. Land, LLC 6565 Collins Avenue Miami Beach FL 33141 PRINCIPAL BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) S 305-866-8855 irasussman@the-beach.net PRINCIPAL BUSINESS TELEPHONE NUMBER CELLULAR TELEPHONE NUMBER EMAIL ADDRESS Pursuant t1+3 .-ity Gode Section 2"48211)(1')(5): A principal of etiiv corporation partnershi a CF other enti who .s. .rb OM a lobb is CM I Gfl that entity �; co p-ns-t-onCO - , for Sirg appearance, a- t (ems direst Cifcont'ngent (O m 3ec,fjcpOaoo itlonto an item shall re.gis erwith the®Jerk as required b, his suosection but shall hot be required to pa any registration fees. 0 If the principal is a Corporation, Partnership or Trust, the following information MUST be provided 0 pursuant to City Code Section 2-482(c): • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(if none,write N/A): See attached Q NAME OF ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,PARTNERSHIP OR TRUST(if none,write N/A): �1�.-�_, CCG IA_J ri Page 1 of 5 DwocVerify ID:ww.docv�ify,�B93267-A9D7-434E-BB3A-33D3A95210EB Page 1 of 5 { 133D3A95210EB J 1111 1I III DocuSign Envelope ID:9F0829D3-A52E-4233-BBA8-E527DED577FB III. ISSUE TO BE LOBBIED: Describe with as much detail as is practical, 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 and Sustainability Committee, City Commission, any City Workshops or Committees, and City Departments, if necessary relating to the property located at � 6 � � Oft vv) I ol c h f1:3 3 If IV. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(a)(4), list the City Commissioner or City 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 of Individual and Contractual Relationship(If yes,explain) YES NO Title of Person to be Lobbied Staff for the Planning Department, Building Department None. X Public Works, and City Administration, PB, HPB, BOA None. X DRB, City Commission, and Mayor as necessary None. X Pursuant to City Code Section 2-482(g), every registrant shall be required to state the extent 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. 6 List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an a appearance of impropriety(if none,write N/A): N O None. 0 None. z V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION — Be Specific. (Note that a contingency fee is prohibited pursuant to City Code Sec. 2-485.3): $0.00 N M Q7 Page 2 of 5 Docverify ID:4CB93267-A9D7-434E-BB3A•33D3A95210E6 y � www.docvenfy.com Page 2 of 5 233D3A95210EB ,III p(qY� 'I III • DocuSign Envelope ID:9F0829D3-A52E-4233-BBAS-E527DED577FB The following six(6)questions MUST be answered: 1) Pursuant to City Code Section 2-488,entitled"Prohibited Campaign Contributions By Lobbyists On Procurement Issues": _Yes XNo: Are you lobbying 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 City Code Section 2-490, entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": —Yes XNo: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoning map designation or change to the City's Future Land Use Map? 3) Pursuant to City Code Section 2-482(h), any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481)who only appears as a representative of a not-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 city clerk as required by this section, but shall not be required to pay any registration fees. _Yes XNo: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement? 4) Pursuant to City Code Section 2-481, the term "lobbyist" specifically excludes the following persons: Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings; any person who only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether direct, indirect or contingent,to express support of or opposition to any item;and any person who only appears as a representative of not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for the appearance. _Yes XNo: Are you providing only scientific, technical or other specialized information; appearing as a representative of a neighborhood association without special compensation or reimbursement or representing a not-for-profit based organization for the purpose of requesting a grant without special compensation or reimbursement? 5) Pursuant to City Code Section 2-491(1), no campaign consultant shall lobby the City Commission for a period of 12 months following the swearing in of any elected official(s) for whom the campaign consultant provided campaign consulting services within the past election cycle. See Section 2-491 for more information. —Yes jNo: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle?If yes,please list the incumbent member(s)of the City Commission: _Yes_No: If yes, has it been less than 12 months since the elected official si whom you provided campaign consulting services was sworn inr 6) Pursuant to City Code Section 2-482(a)(4)a., a lobbyist who has within the past election cycle provided campaign consulting services to an incumbent member of the City Commission (which lobbying activity is not otherwise prohibited by Code section 2-491) shall disclose such particular service on his/her lobbyist registration form and shall orally disclose such particular service before lobbying the City Commission at a public meeting. Yes XNo: Have you provided campaign consulting services to an incumbent member of the City Commission within the past election cycle?If yes,please list the incumbent member(s)of the City Commission: N 0 N Yes No: If yes, were you pro ised or did you receive economic consideration in e change for camtaign In -- cow SUltin NEI:,iCe ISil 0 0 M M 8 TO BE COMPLETED BY CITY CLERK'S STAFF ONNLLY co Annual Registration fee: .[ ]Yes[•lIo Amount Paid$ MCR# pI(A Alt_ Date Paid a Lobbyist Registration Form received and verified by: JS F<\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 09-20-18 REG.doc Revised 09/20/2018 C, rn Page 3 of 5 Dwew.doce ID: rify4Cm93267-A9D7-434E-B63A-33D3A95210E8 I Page 3 of 5 333D3A95210EB I ,Ill awnIII DocuSign Envelope ID:9F0829D3-A52E-4233-BBA8-E527DED577FB VI. SIGNATURES UNDER OATH: ON FEBRUARY 28 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE LOBBYIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILED EVEN IF THERE HAS BEEN NO EXPENDITURE OR COMPENSATION DURING THE REPORTING PERIOD.' Si nature of Lobby ist: IPa �IASSwtatn Date 6/17/2022 g y co5Cer2C05734CD... I do solemnly swear or affirm that all of the foregoing facts, statements, and disclosures in this form are true and correct, and that I have read or am familiar with the provisions contained in Chapter 2, Art. VII, Division 3, entitled "Lobbyists" of the Miami Beach City CoetertliditIteitivorting requirements. Signature of Lobbyist: lra S.MSKialn. 6/17/2022 Date 6/17/2022 Signature of Principal: lrtL S.U.SSwtatn, Date `—C85E6F2CB57346D... VII. NOTARY SIGNATURE AND SEAL: LOBBYIST: PRINCIPAL State of Florida State of Florida County of: Miami-Dade County of: Miami-Dade Sworn to(or affirmed)and subscribed before me, Sworn to(or affirmed)and subscribed before me, by means of 0 physical presence by means of 0 physical presence or 0 online notarizati9g,1712022 or®online notarization, this day of ,20_, by this_day of 06/17/2022 ,20_, by Ira Sussman Ira Sussman NAME OF LOBBYIST NAME OF PRINCIPAL _Produced ID _Produced ID FORM OF IDENTIFICATION FORM OF IDENTIFICATION X X Personally Know "`"°' _Personally Urn �... 0 m pa _6 Signature of Notary Public Signature of Notary Public r Ben Fernandez , Ben Fernandez _ _lu ar I. d Name of Notary,Typed, Printed or Stamped !lefty etty Llerena w Commission#HH 221018 Betty Lierena N ICLotary Public-State of Florida 1 Commission#HH 221018 a My Commission Expires Mar 05,2026 a Kfotary Public State of Florida a, 0 � P y Commission Expires Mar 05,2026 a,M a 0 m 1 Theas?}`Jr 'urz7�f1T>7 .4'ic7Ccifi7��1T,ilsochmc�in.b-fnmeaAti g persons: _ _ _ _ _ _ - _ m Expert witnesses who provide only scientific,technical or other specialized information or testimony in public meetings;any person who O only appears as a representative of a neighborhood association without compensation or reimbursement for the appearance,whether c direct, indirect or contingent, to express support of or opposition to any item; and any person who only appears as a representative of N not-for-profit community based organization for the purpose of requesting a grant without special compensation or reimbursement for m the appearance. a Page 4 of 5 '! DocVerify ID:4CB93267-A9D7.434E-BB3A-33D3A95210EB Page 4 of 5 433D3A95210EB ,III ,I III 1 www.docverify.com DocuSign Envelope ID:9F0829D3-A52E-4233-BBA8-E527DED577FB MIAMI BEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov Office of the City Clerk Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov Tel: 305.673.7411, Fax: 305.673.7254 Ira Sussman NAME OF LOBBYIST: 1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT Pursuant to City Code Section 2-485(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 to 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 Statement or pay the assessed fines after notification. Any lobbyist, who fails to file the required Statement by April 30th of each year, shall be automatically suspended from lobbying until all fines 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 Withdrawal 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 N commencing October 1 of each year, and the fee for such annual registration shall be $500.00 pursuant to Section 2-482 of the Miami Beach City Code. N Imo, DocuSigned by: o I lVa SIASSKAN . 6/17/2022 C85E6F2CB573460... Signature of Lobbyist Date r rn F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form Revised 03-11-20 REG.doc m Page 5 of 5 iry DocVerify ID:4CB93267-A9D7.434E-BB3A-33D3A95210EB Page 5 of 5 533D3A95210EB 'III M ,I II I www.docverify.com CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 1. CORPORATION If the property which is the subject of the application is owned or leased by a CORPORATION,list ALL of the stockholders,and the percentage of stock owned by each. Where the stockholders consist of another corporation(s),trustee(s),partnership(s)or other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having the ultimate ownership interest in the entity.* S.F. Land, LLC. CORPORATION NAME NAME AND ADDRESS %OF STOCK S.F. Land Trust f/b/o Joel.Sussman Family 40% 6565 Collins Avenue Miami Beach, FL 33141 S.F. Land Trust f/b/o Ira Sussman Family 50% 6565 Collins Avenue Miami Beach, FL 33141 S.F. Land Trust f/b/o Perri Stern Familmm 10% 6565 Collins Avenue Miami Beach, FL 33141 CORPORATION NAME NAME AND ADDRESS %OF STOCK IF THERE ARE ADDITIONAL CORPORATIONS,LIST OTHERS,INCLUDING CORP.NAME(S)AND EACH INDIVIDUAL STOCKHOLDER'S NAME,ADDRESS, OFFICE AND PERCENTAGE OF STOCK ON A SEPARATE PAGE. NOTE:Notarized signature required on page 8 6 CITY OF MIAMI BEACH DEVELOPMENT REVIEW BOARD APPLICATION DISCLOSURE OF INTEREST 2.TRUSTEE If the property which is the subject of the application is owned or leased by a TRUSTEE,list the beneficiaries of the trust and the percentage of interest held by each. Where the beneficiary/beneficiaries consist of corporations(s), another trust(s), partnership(s)or other similar entity,further disclosure shall be required which discloses the identity of the individual(s)(natural persons)having the ultimate ownership interest in the entity.* S.F. Land Trust f/b/o Joel Sussman Family TRUST NAME NAME AND ADDRESS %OF STOCK Matthew Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Elizabeth Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Benjamin Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Stephanie Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 S.F. Land Trust f/b/o Ira Sussman Family TRUST NAME NAME AND ADDRESS %OF STOCK Mollie Sussman Davis 10% 6565 Collins Avenue, Miami Beach, FL 33141 Paige Sussman Danowit 10% 6565 Collins Avenue, Miami Beach, FL 33141 Max Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Rachel Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 Miriam Sussman 10% 6565 Collins Avenue, Miami Beach, FL 33141 S.F. Land Trust f/b/o Perri Stern Family TRUST NAME NAME AND ADDRESS %OF STOCK Meredith Rishty 10% 6565 Collins Avenue, Miami Beach, FL 33141 3. PARTNERSHIP/LIMITED PARTNERSHIP If the property which is the subject of the application is owned or leased by a PARTNERSHIP or LIMITED PARTNERSHIP, list the principals of the partnership, including general and limited partners. Where the partner(s)consist of another partnership(s), corporation(s),trust(s)or other similar entity,further disclosure shall be required which discloses the identity of the individual(s) (natural persons)having the ultimate ownership interest in the entity.* PARTNERSHIP or LIMITED PARTNERSHIP NAME NAME AND ADDRESS %OF STOCK NOTE:Notarized signature required on page 8 7