Joanna Rose-KravitziAMIBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCCo7miamibeachfI.gov
Telephone: 305.673.741 1
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):
e` I am a resident of the City of Miami Beach for six months or longer.
Home Address /"L yJ y , !41,1 r 14 • VV
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
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 compaf ly. 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.
42— i / 1
Sign at Date
i7C] `i}f' ltir'C bi
P ' ted Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of Xphysical presence or online notarization,
this 15tbay of December , 20 21 by
X Produced ID
Joanna Rose -Kravitz
City of Miami Beach Board/Committee Member)
FL Drivers License
Form of Identification
Personally Known
Signature of Notary Pubic
Name of Notary, Typed, Printed, or Stamped
rCY CHARLES J. DAGOSTIN
a
MY COMMISSION # HH 165705
a: EXPIRES: December 14.2025
I_ ` Bonded ThruNotary Public Underwrlters
NOTARY SEAL)
Received December 17, 2021
Office of the City Clerk