Don Washburn/AB Green Raleigh, LLCm MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
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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, deasion 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 bond 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 Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I.)
Washburn Don
BUSINESS NAME AND ADDRESS (Number and Street) ~ (City) (State) (Zip Code)
c% The Audio Bug, Inc. 3800 Hillcrest Drive, Unit 102 Hollywood, FL 33021
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
(954) 983-2788 (954) 983-2789 audiobuglQaol.com
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
AB Green Raleigh, LLC.
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~,,, BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
The Raleigh Hotel 1775 Collins Avenue Miami Beach FL 33139
TELEPHONE NUMBER: FAX~BER: (Optional) EMAIL: (Optional)
305.534.6300
Fitl out this section if principal is a Corporation, Partnership or Trust (Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
Andre Balazs, Chief Officer
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE
OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
Please see attached
II. SPECIFIC LOBBY ISSUE:
Conditional Use Permit for Raleigh Hotel
Issue to be lobbied (Describe in detail):
111. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2-482(g) include a
statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual/Title B An Financial, Familial or Professional Relationshi
Mayor None
Commissioners
City Administration; City Attorney's Office; None
Cit Committees; Cit Boards
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOfJRLY, FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
$3,000.00 flat rate
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). $3,000.00 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 6a No: Are you lobbvinsi on a present or Dendina bid for goods eauiament or services or on a
present or Dendina award for Goods eauiament or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"IobbyisY' 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 6a No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
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: 1C /`(,
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 Lobb st's signature
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
personally known (Principal)
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State of.pzr County of Mien~atte
Sworn to and su~.s`c_r,ibed before me
This I') day of s~fs,~, 200 ~l
Signature of Public Nota~r -State of ~lerade-
Notarization of Principal's signature
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TO BE COMPLETED BY CITY CLERK'S USE ONLY ~,
Annual Registration fee: )Yes [) No Amount Paid S - MCR # S Date Pald
Lobbyist Registration Form received and verified by:
F:ICLER\LOBBYIS11Lobbyist Registration Form 32708.doc _ ., e_..~__~ ....:.,~......,..
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
$3,000.00 flat rate
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). $3,000.00 flat rate
The following information must be answered:
1) Pursuant to Miami Beach Ciry Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^Yes 6a No• Ars you lobbvina on a present or pending bid for goods eaulpment or services or on a
present or pending award for Goods equipment or service? --
2j Pursuant to Miami Seach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
Yes 6a No• Are you lobbvina on a pending implication for a Development Agreement wfth the City or
a°plication for chance of zoning man designation or chance to the Citv's Future Land ILss Map?
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"IobbyisY' 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 Gerk as required by this
section but, shall not be required to pay any registration fees..
Yes ~ No: Are you representing snot-for-proflticorporation or entity without special compensation or
reimbursement.
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V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client: (/
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Ident~cation
Personalty known (Lobbyist)
^ Produced ID
^ Personally known (Principal)
Form of Identification
Vii. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This ~' day of _ Sa, e , 200
Sig ure of Public tary - Stat lorida
N rization of L b 's s] ature
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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 n 'signature
TO BE COMPLETED BY CITY CLERK'S USE ONLY
Annual Registration fee: [ ] Yes j ] No Amount paid S MCR # i Date Paid
Lobbyist Registration Form received and verHfed by:
F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc Revised 03lZ712008
I do solemnly swear that all of the fo i facts are trt,1 an cone and that I have read or am familiar with the
provisions contained in Section 2-482 o the Miami Be~ch~y ~de~n~ all rep~t~g requirements.
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov
CITY CLERK office
Tel: 305.673.7411, Fax: 305.673.7254
CityClerkCy2miamibeachflsgov
LOBBYIST MAME: Don Washburn
I understand that no later than October 1" of each near, 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 withdraws in writing.
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MIADOCS 3576087 7
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