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Donald J. Washburn - O Entertainment Group USA, LLC
i MIAMI A t)00 0, 0 y � l, �t 1 I City of Miami Beach Office of the City Clerk J� 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, Donald J. NAME OF LOBBYIST: (Last) (First) (M.1) 3800 Hillcrest Drive, Unit 102, Hollywood, Florida 33021 BUSINESS NAME AND ADDRESS Number and Street)) (City) (State) (Zip Code) (954) 983-2788 (954) 983-2789 audiobug1 @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: O Entertainment Group USA, LLC NAME OF PRINCIPAUCLIENT: 185 SW 7th Street,Suite 2210, Miami Florida 33130 BUSINESS NAME AND ADDRESS (Number and Street) (City)y (State) (Zip Code) (305)606-7582 N/A antarsosa @yahoo.com 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: Antar Sosa, O Entertainment Group USA, LLC • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: See Attached Exhibit B A Conditional Use Permit for a Neighborhood Impact Establishment at 2000 Collins Avenue,(Units 6,7,8 and 10);any approvals under Planning Board File No.1609;and related zoning and development issues. Issue to be lobbied(Describe in detail): ul. Q3 f 1 S/1 tIDfY�!©UAt=S t0$E.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 eneral 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 City of Miami Beach Planning Board 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. Sec 2-482 Any Financial,Familial or Professional Relationship ,` I j i ) 5 .1 j None HAP an �f'\ C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook{3L LGQDDH\Lo bbyist Registration Formrevised 5-30-2012.doc '1_X ,5r IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) $5,000.00 Flat Fee B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): $ 5,000.00 Flat Fee (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 E No: 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 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 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 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. ❑ Yes ®No: 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, 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 SHA BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. ��li/0 Signature of Lobbyist I do solemnly swear that all of A foregoing facts are tr a and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Pe*h City C e a al r orting a uirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST QENTIFICATION: PRINCIPAL IDENTIFICATION: El Produced ID * -:2 a o N X Produced ID 2QQ-000 Form of Identification °D o Form of Identification S N 0 c 2 n � to x o El Personally known (Lobbyist) ; a w .y El Personally known(Principal) ` uj sc- s E E c� x VII. Rlorid TURE AND STAMP NOTARY: n "' Z �'U Sta Co my of M+eff -Bede State of Florida, County of Miami-Dade S or t bs ed befo m Swor d subscribed before me his a f 01V— ?ne Is day of ZDCnj 201 t S1 iY M ty� -S�,y«. SST,•� �`7 Signature of Public Notary-State of Florida igna ufe ublic Notary State of Flo ' a Notarization of Lobbyist's signature No Jwizavon of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc U Revised 1/11/2011 i F:\CLEI ti5lration Form.doc Revised 04/27/2012 MIANAIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1 , Fax:305.673.7254 LOBBYIST NAME: Donald J. Washburn I understand that no later than February 28 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, or I am no longer lobbying on that issue or for that principal, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist(or principal) who falls to timely file a Statement and in addition to any other penalties which may be Imposed as provided in Section 2-485.1, a fine of$50.00 a day shall be assessed for all Statement(s) 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, 2012, 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. /),0 If.1 ///�Z,�/Z 1e-l— 4& (� , Signature: Da e: C:\Users\clerhatMppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGODDH\Lobbyist Registration Formrevised 5-30-2012.doc EXHIBIT "B" DISCLOSURE OF INTEREST O ENTERTAINMENT GROUP USA,LLC Name and Address % of Ownership Omar Quesada 45% Paseo Los Insurgentes 2110 Colonia linda vista Leon Guanajuato Mexico Oscar Guillermo Webber Muzquiz 45% Paseo Los Insurgentes 2110 Colonia linda vista Leon Guanajuato Mexico Antar Sosa 10% 185 SW 7"' Street, #2210 Miami, Florida 33130 I