Donald J. Washburn - Chalk's on the Beach MIAMIBEACH
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 My
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 �•
NAME OF LOBBYIST: (Last) (First) (M•I)
The Audio Bug, Inc. 3800 Hillcrest Drive, #102 Hollywood Florida 33021
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(954)983-2788 (954)983-2789 audiobual(abaol.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
Chalk's on the Beach, LLC—Joseph Blount, Manager
NAME OF PRINCIPAL/CLIENT:
Chalk's on the Beach LLC 605 Lincoln Road Suite 200 Miami Beach Florida 33139
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)674-1712 (305)673-4879 jblount55 @gmail.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:Joseph Blount, Manager
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: See attached exhibit
II. SPECIFIC LOBBY ISSUE:
Development approvals and permitting issues for property located at 1234 Washington Avenue, Miami Beach, FL
Issue to be lobbied(Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A)Full Name of Individual/Title B)Any Financial,Familial or Professional Relationship
Planning Department and Building Department Staff None
PB,HPB, BOA,City Commission,as necessary* None
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*Unless an issue is legislative in nature,PB,HPB,BOA,and City Commission members are not lobbied outside of a jpudlig'Itebring sett4.'.�
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) $3,500 Flat Rate
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $3.500 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 X 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 X 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 X NO' Are you representing a not-for-profit corporation or entity without special compensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT 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 TH PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO PENDITUIE 7C7 P NSA N URING THE
REPORTING PERIOD.
Sig ha r of Lobbyist
I do solemnly swear that all f the foregoing facts are true and correct and that I have read or am
familiar with the provisions ntained in Section -482 of the Mia each City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATIO PRINCIPAL IDENTIFICATION:
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Produced ID t 1 ��� T s7�Gl Produced ID
Forr (Il ip[I- Form of Identification
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Personally knl n7�i jLobbYist) 'N'; Personally known (Print "'N. : KAREN LEWIS
* MY COMMISSION#EE014741
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VII. SIGNATURE" ;gr °r� '6�F NQttY: �J��,tid � EXPIRES August 05,2014
i, ,.p ded hN�`BF. Q`� (407)398-0153 Floridallota Service.com
State of Florida, County of, F0���� State of Florida, County of Miami-Dade
Sworn to and subscri foVIdI01111� Swor d subscr'b efore me
This r of - 20 — Thisday of�
Signature of Public Notary—State of Florida Signature f Public Notary—State of Florida
Notarization of Lobbyist's signature Notariza ' n of Principal's si nature
FOR CLENLY
Annual Registration fee: [ ]Yes[ ] No Amount Paid � MCR# Date Paid �v
Lobbyist Registration Form received and verified by: P ' Entered By:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04
: .
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139.www.miamibeochfl.gov
CITY CLERK Office CEtyClerkCmiamioeachf1.gov
Tel:305.673.741 1 ,Fox:305.673.7254
LOBBYIST NAME: Dons W wqs�y6 ury
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.
( 2-
Signature: Date:
EXHIBIT
DISCLOSURE OF INTEREST
Chalk's on the Beach,LLC,a Florida Limited Liability Company
605 Lincoln Road,Suite 200
Miami Beach,Florida 33139
NAME OF INTEREST HOLDER % INTEREST
1. Joseph W.Blount Revocable Trust 75.0%
Joseph W. Blount, Trustee
2535 Lake Avenue
Miami Beach, Florida 33140
Joseph W. Blount, Beneficiary 100%
2535 Lake Avenue
Miami Beach, Florida 33140
2. Robert Chalk 10.0%
3451 NE 1 s`Avenue
Apartment M704
Miami, Florida 33137
3. Sayra Moto 15.0%
1368 Normandy Drive
Miami Beach, Florida 33141
TOTAL for Chalk's on the Beach,LLC 100%