Donald Washburn - 1906 Collins, LLC MIAMIBEACH
City of Miami Beach Office of the City Clerk 1�0
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.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 - X54)983-2789 audiobugl @aol.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
1906 Collins, LLC—Mathieu Massa, Manager
NAME OF PRINCIPAL/CLIENT:
1906 Collins,_LLC 999_Brickell Avenue Suite 600 Miami Florida 33131_
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)965-7882 (305)396-2857 mmassa @massainvestment.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: Mathieu Massa,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 1908 Collins Avenue
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
zz
*Unless an issue is legislative in nature,PB,HPB,BOA,and City Commission members are not lobbied outside of a public hearing sewng:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) $
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (Required). $ 7
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 amending application for a Development Agreement with the City or
application for chance 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 1sT 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 CALEND R YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES O. COMPENSATION DURING THE
REPORTING PERIOD.
�t
Sig at a of Lobbyist
I do solemnly swear that all of' foregoing facts are true and'correct and that I have read or am
familiar with the provisions contained in SectiQn 2-482 the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFYCAT� � I'Y ON: PRINCIPAL IDEeNTrIFICATION:
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Produced ID -ii} ��"
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Produced ID
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VII. SIGNATURE IkT�p�S�A&P O_F N�'P}�ISf: y !un 28,2015
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State of Florida, County rani 758 o� y c mrr
State of Florida Flonda C�,art of Miami-Dade
Sworn to and subscribeda,.BB�dedttN ��e:�oQo Sworn and subs ttSfhr' e
Th' _} _day o • �oF���` This (0 day of__ , 20_IZ
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Signature of Public Notary—State of Florida Signature of Public Notary—Stat of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid. �— MCR# A _Date Paid Z -,?,7,
Lobbyist Registration Form received and verified by: Entered By:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04
City of Miami Beach, 1 700 Convention Center Drive,Miami Beach, Florida 33739.www.miamibeachfl,9ov
CITY CLERK Office CityClerk@miomibeachfl.gov
Tel:305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ono
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,
Signature: Date:
EXHIBIT
DISCLOSURE OF INTEREST
for
1906 Collins, LLC
999 Brickell Avenue, Suite 600
Miami, Florida 33131
NAME OF INTEREST HOLDER % INTEREST
1. Baoli America Group Corp.,a Florida Corporation 50%
1906 Collins Avenue
Miami, Florida 33139
MIG US, LLC, a Florida Ltd. Liability Company, Manager 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
Mathieu Massa, Manager of MIG US, LLC 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
2. MIG US,LLC,a Florida Ltd.Liability Company 50%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
Mathieu Massa, Manager of MIG US, LLC 100%
999 Brickell Avenue, Suite 600
Miami, Florida 33131
TOTAL for 1906 Collins,LLC 100%