Patricia Henao van Beek 12/31/2212/31/22 12/31/26
3/18/2021 2/25/2021
3/18/2021
3/18/2021
3/18/2021
3/18/2021
Received March 18, 2021Office of the City Clerk
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf gov
Telep hone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA •
couNTY or Mignu- Dade
am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[4 4am a resident of the City of Miami Beach for six months or longer.
[] 1have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
D I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
Dt±
signaiR e
Pa+iua Henao-van 2ek_
3//1/2021
Date'=
Printed Name
NOTARY
Swom to (or affirmed) and subscribed before me, by means of Xphysical presence or .l online
t . t· th· 17 th d f M arch 20 21b TOig[ld[Q[], Il id l .' '}
P atricia H enao van Beek
________________ (City of Miami Beach Board/Committee Member).
X
Produced ID FL D riv ers L icense
Form of Identification
Personally Known
Ce.a D'get
Signature of Not ary Pub lic
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Charles J. DAgostin
NOTARY PUBLIC
STATE OF FLORIDA
Comm GG168171
Expires 12/14/2021
X
Received March 23, 2021
Office of the City Clerk