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Donald Washburn/IC, 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 modfication of any ordinance, resolution, action or derision of any commissioner, any action, decision, recommendation of the Ciiy Manager or any aty board or committee; or any action, derision or recommendation of any aty personnel during the time period of the entire decision-making process on such action, decision or recommendation that fa~eseeabty will be heard or reviewed by the aty commission, or a aty bond or conunittee. The term specificalty inductee the principal as well as any employee engaged in bbbying activities. The term "Lobbyists" has specific exclusions. Please Hafer tD Ordinance 2004-3435. Washburn Donald J. NAME OF LOBBYIST: (Last) (First) (M.I.) c1o The Audio Bug Inc. ~~~~ 3800 Hillcrest Drive Hollywood FL 33021-7937 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (954) 983-2788 (954) 083-2789 audiobu9l@aol.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: LOBBYIST RETAINED BY: IC, LLC NAME OF PRINCIPAUCLIENT: IC LLC 2200 Biscayne Boulevard Miami FL 33137 BUSINESS NAME AND ADDRESS (Number and Street) ~ (City) (State) (Zip Code) 5L374-5700 {305) 847-3354 ~ mkramer(d~crescentheights.com TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if prindpal is a Corporation, Partnership w • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Russell W. Galbut and Irving Cowan IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°i6 OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: c-=' ~., c, Russell W. Galbut (50%), Managing Member ~ c°„ c:- Irving Cowan (50%), Managing Member ~ ,. r ., 11. SPECIFIC LOBBY ISSUE: ~," ~ ; Conditional Use Approval (1) to permit the use of a robotic partcing system in a commercial maa~%rkir~ garage at 1826 Collins Avenue, which inductee a restaurant within the commercial space; and (2) to" opt to tl~ garage after midnight. -:~ ~ Issue to be lobbied (Describe in detail): III. CITY AGENCIESANDMDUALS TO BE LOBBIED: (Pursuant to City Code Section 2~182(g) indude a statement of the extent of any business, fnanrial, familial, professional or other relationship, giving rise to an appearance of an irnnpropriety, with any City personnel sough to be k~bied; further, pursuant to City Code Section 2- 482(a)(4) indude a statement of any contactual relationship (paid or unpaid) from 12 months preceding the oorrnnencerr-ent of service of Cily personnel to be lobbied.) A Frdl Name o4f IadividuaYTitle B Financial Familial a Pr+desaional Raladionshi City of Miami Beach Planning Boats None `p City of Miami Beach Planning Staff None / ~'f, City of Miami Beach Mayor/Commissioners None mil'' City of Miarni Beach Committees None `! IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): LOBBYIST DISCLOSURE: (Required) $3,000 Flat Rate. B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $3,000 Flat Rate. 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 ~I No: Are you lobbvinq on a pending application fora .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 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 ~ No: Are you representing snot-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON OCTOBER 1g~ OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED PERIOD. Signature of Lobbyist -Donald J. Washburn 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: Russel VI. LOBBYIST 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 , 2008 Signature of Public Notary -State of Florida Notarization of Lobbyist's signature as Managing Member of IC, LLC PRINCIPAL IDENTIFICATION: ^ Produced ID Form of Identification Personally known (Principal) State of Florida, County of Mi i;© Sworn to and sub cribed bef e~ T day of , 2 YN, 4'? ~'iF Ji' j1 Sig tur f Publ N ~ ary - t e No riza ' n of Principal's signature Notary PtibBC - 8tste ~ Floes ~' lion E Afar 18. YBt~ Commission * DD 844032 Bided Though Na6or~s1 Notan A.a I U tit GUMPLETED BY CITY CLERK'S USE ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid 5 MCR # S Date Paid Lobbyist Registration Form received and verified by: F:\CLERILOBBYISlILobbyist Registration Form 32708.doc Revised 03/27/2008 c~-- ~~~~~ ~~~c~ City of Miami Beach, 17x0 Gonvention Center Drive, Miami Beach, Florida 33939, www.miamibeachfl.oov CITY CLERK office CityClerkCa~miamibeachfl.gov Tel: 305.673.7411, Fax: 305.673.7254 Donald J. Washburn LOBBYIST NAME: 1 understand that no later than October 1" of each veer, I must file the following forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues. 1) Lobbyist Expenditure Form 2) Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and for code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office for lobbyist withdrawal in writing. C~~%~/1 ~ Signature: f)onald J. bum ~~