Dale StineMIAMI BEACH
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamjbeachfl gov
Telep hone: 305 .673. 7 411
City of Miami Beach
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check(✓) all that apply):
� I am a resident of the City of Miami Beach for six months or longer.
HomeAddress:_1573 Pennsylvania Ave. 1N Miami Beach, Fl 33139
!Kl 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: __ HeartPrints, Inc.
Business Address: ___ 1573 Pennsylvania Ave. 1 N Miami Beach, FL 33139
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).
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.
Signature
!)� f cfaw December 1, 2021
Date
Dale G Stine
Printed Name
Received December 17, 2021
Office of the City Clerk