Daniel RoblesCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCC@miamibeachfi.pov
Telephone: 305.673.741 1
Received May 19, 2022
Office of the City Clerk
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(J) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 5838 Collins Ave Apt. 6E Miami Beach, FL 33140
1 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).
Name of Business
Business Address
❑ 1 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).
Name of Business
Business Address
"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.
i�1i l ►��l.;l _� _._
Signature
Daniel Robles
Printed Name
NOTARY
5/19/2022
Date
Sworn to (or affirmed) and subscribed before me, by means of ❑Xphysical presence or ❑ online notarization,
this
19thMayof MaY 22
,20 by
X
Produced ID
Daniel Robles
(City of Miami Beach Board/Committee Member)
FL Driver's License
Form of Identification
Personally Known
SignaCharPesY61- g stin
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGOSTIN
MY COMMISSION # HH 165705
Z EXPIRES: December 14, 2025
80nded Tf tm NWq PUb0a Underwriters
(NOTARY SEAL)