Don Washburn - City Middle y
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City of Miami Beach Office of the City Clerk CD��
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 3800 Hillcrest Drive, Unit 102 Hollywood FL 33021-7937
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
954-983-2788 954-983-2789 audiobu 1 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:
City Middle, LLC .
NAME OF PRINCIPAUCLIENT:
2001 Meridian Avenue, Unit 504, Miami Beach, FL 331.39
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
(305)807-2654 None gboyerl 01 @gmail.com
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
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Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] _ w
NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY:Glenn Boyer 3
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IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN;SU09000RPGRATION,
PARTNERSHIP OR TRUST:
ii.SPECIFIC LOBBY ISSUE:
Development Approvals and Permitting Issues,including,but not limited to Design review Approval for a rooftop miniature golf`course tacility at 1691
Michigan Avenue,Miami Beach,FL
Issue to be lobbied(Describe in detail):
Ill. CITY AGENCIEWINDIVIDUALS 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
arson'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
Tanning Department and Building Department Staff None
B, DRB, HPB, BOA, City Commission, as necessary* None
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(g)Any Financial,Familial or Professional Relationship
FXLERIALUaFORMSTOBBYIST FORMSTobbyist Registration Form.doc V060107
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required) L gz.
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 X No: Are you lobbyina on a present or pending bid for goods,eauipment or services.or on a present or peodina
award for goods.eauipment 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 lobbvina on a pending application for a Development Agreement with the City or application for
chanae of zoning map designation or chanae 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 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
E�XPPENDITURES OR
Signature of Lobbyist
I do solemnly swear that all of the going facts re true and orrect and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea h ity Code 'a po.in require a ts.
Signature of Lobbyist:
Signature of Principal/Client: J
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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❑ Produced ID Nom_ ❑ Produced ID
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Form of Identification Form of Identification Q
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Personally known(Lobbyist) G R Personally known
(Principal)VII. o SIGNATURE AND STAMP OF
NOTARY: t
State of Florida, County of Miami-Dade State of Florida,County of Miami-Dade
Sworn t subscribed-before me Sworn and subsc 'bed before me
This f 2� oo ' . This day f ,QD4-2-ol�J
Signat re of Pub 1 ota —State of Florida Signat a of c Notary—State of Florida
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Notarization of signature Notarization of Prin�signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
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Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date P ar 13
Lobbyist Registration Form received and verified by.
/\AIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139,www.miamlbeachfl.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.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails 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.
11-2
Signature: Date:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc