Nicholas Sergentanis 12/31/2112/31/22 12/31/28
6/1/2021 5/25/2021
6/2/2021
6/1/2021
6/1/2021
Received June 2, 2021Office of the City Clerk
11 A MI H
City of Mi am i Beach
17 00 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF [¿- de
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check (/) all that apply):
[]1m a resident of the City of Miami Beach for six months or longer.
D I 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).
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
sited in it are true.
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Printed Name {/
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of g physical presence or [] online
notarization, this " day or June _2o_y
Nicholas Sergentanis ________________ (City of Miami Beach Board/Committee Member).
X Produced ID FL Drivers License
Form of Identification
Personally Known
Ciada 'gt
Signature.pf_Ngay Pplig, _ Charles J. D'gosun
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
®
RY Charles J. DAgostin
NOTARY PUBLIC
l STATE OF FLOR IDA o Comm# GG168171
es Expires 12/14/2021
X
Received June 2, 2021
Office of the City Clerk