Seth CasselMIAM I BEACH
City of Miami Beach
1700 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 MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
( ✓) all that apply):
X I am a resident of the City of Miami Beach for six months or longer.
Home Address 4450 N Jefferson Ave, Miami Beach, FL 33140
o 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).
Name of Business -------------------------
Business Address _
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).
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. f I l1 12-31-2021
Signature
Seth Cassel
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by_means of o phy5/cal presence or online notarization, .3la 'tele.2L Se/, ('As
Produced ID
(City of Miami ,Peach Board/Committee Member).
[ bot Lieu se g¿iii¿, CHARLES J. DAGOSTIN
$",Z, MW cosso HH 16s7os
j,9S.is; ExPREs: December 14, 2025
f;¿é" Bonded Tru Notary Public Underwriters
(NOTARY SEAL)