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Don Washburn - RP Hotel Holdings, LLC trA t A A AIDC / 11 I. ACH itty 0024 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 Ordinance 2004 -3435. Washburn Don NAME OF LOBBYIST: (Last) (First) (M.I) The Audio Bug, Inc. 3800 Hillcrest Dr. Suite 102 Hollywood FL 33021 - 7937 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) (954) 983 -2788 (954) 983 -2789 audiobugl ©aol.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes: address, phone, or e-mail address. I. LOBBYIST RETAINED BY: RP Hotel Holdings, LLC NAME OF PRINCIPAUCLIENT: RP Hotel Holdings, LLC 100 Fillmore Street, Suite 600, Denver CO 80206 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 720- 284 -6418 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2482 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: RP Hotel Holdings, LLC • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See Attached II.SPECIFIC LOBBY ISSUE: The James Hotel at Royal Palm Issue to be lobbied (Describe in detail): iii. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's commencement of service with the city to the present date, stating the general nature of the subject contractual relationship. Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO title of person to be lobbied Historic Preservation Board, Board of Adjustment Planning Board City Departments 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. !,(1! ; Sec 2- 482(g) Any Financial, Familial or Professional Relationship S fj : 1 1 4 c l 6 1 5 1 1 1 4 1 1 0 Z 4� 1 +.. .// �1 i IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) . S L ).,r->I , C V ` 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 Q No: Are ou Iobb In on a • resen or • - ■'n, bld for . oods e • ui • ment or _ - v - or on a 'resent or • endln 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 ® No: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zonin map deli nation or change to the City's Future La nd 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 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 clerk as required by this section but, shall not be required to pay any registration fees. Q Yes A NQ; Are you representing a not -for profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON FEBRUARY 28th OF EACH YEAR, EACIj 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 SH BE FILED,VE IF THE E HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. . . _ 4 k U' Signature of Lobbyist I do solemnly swear that all oft : •regoing fa.. - are t ue and c rect and th -t I have read or am familiar with the provisions contained in Section 2 -482 of the Miami : • - - . / City Co. and - . porting equirem - ,. . Signature of Lobbyist i _ —� A . / 6'' ,f > Ap . -------- r Signature of Principal /Client: • �' � .�' • .••• "'•••• VI. LOBBYIST IDENTIFICATION: I c N o PRINCIPAL IDENTIFICATION: � Crs — ' \ /Produced ID '1V $1 1 0 Produced ID t ; 0 . P UBLtC . F orm of identification . v, Form of Identification ' -. ••........ x o ❑ Personally known (Lobbyist) I ' W . y Personally known ( Principal) . o n , E . fly Commission &p s Sept 10, 201.E VII. SIGNATURE AND STAMP OF NOTA A c°) o . 1 c-, State of Florida, County of Miami -Dade I �� ..•,.• � � State of- coda, County of-4 o " •�. Sworn to arid subscribed before me �•.;>c / Sworn and subscribed before me This ..13` day of AuC,I,JSt , 2011 134 db This 3 may of 11 a 9 • ' �.' I iZi ► �'- � is =.r ,••,,,. ►•lt Signature Notary Signature f Public Notar,- State of Florida � � • � � Z Si nature of Public Notar State of - v ^1.6 � Notarization of Lobbyist"'i signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY I- <:-) 1 Q Annual Registration fee: [ ] Yes [ ] No Amount Paid $ S�� .-- MCR # `'� 1/ 2.- / Date Paid o / ` / . Lobbyist Registration Form received and verified by: F. \CLER\SALL\aFORMS \LOBBYIST FORMS \Lobbyist Annual Registration Forrn.doc / At:€ Revised 1/11/2011 D. / \ / \ I ,/\/\/\ BE C 11 City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: Don Washburn I understand that no later than February 28th of each year, I must file the following form, 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 and Compensation 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 of lobbyist withdrawal in writing. /6/ )0/2/44 Signature: Date: