Roger Shields 12/31/222/1/2021
12/31/22 NTL
2/1/2021
2/1/2021
4/27/2021
4/27/2021
4/27/2021
4/27/2021
Received on April 27, 2021Office of the City Clerk
27th April
IA MIBE
City of Miami Beach
1700 Convention Center Drive
Mi am i Beach, Florida 33139
OF FICE OF TH E CITY CLERK
Email: BC@miamibeachf.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA, _,3
COUNTY OE Miami-1 )ade
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check (/) all that apply):
O I am a resident of the City of Miami Beach for six months or longer.
~ have 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}.
O 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
#"f(__ 2444000292]
Signatur~~ e,(
PrintedN~
h 5.±- Date
NOTARY
Sworn to ( or affirmed) and subscribed before me, by means of X physical presence or D online
notarization, th; Ch3a, r March 20_21by
Roger D. Shields (City of Miami Beach Board/Committee Member).
X Produced ID FL Drivers License --------------- Form of Identification
2EE"%A.
Signature of NQtary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
1A!a,, Charles J. DAgostin
®NOTARY PUBLIC
STATE OF FLORIDA
Comm# GG168171
f5 eoires 12/14/2021
X
Received on April 27, 2021Office of the City Clerk