Lynette LongMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCC@miamibeachfl.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):
q I am a resident of the City of Miami Beach for six months or longer.
Home Address 650 West Avenue, Apt 501, Miami Beach, FI 33139
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 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.
Lynette Long 12/ 15/2021
Signature Date
Lynette Long
Printed Name
NOTARY
Sworn to (or affirmed and subscribed before me, by means of o physical presen eXonline notarization,
thfs l"- Iday eCeO>A20 '?-'by /ye 7D
City of Miamieach Board/Committee Member).
Produced ID
Form of Identification
7all Known
SignkA o ota ublic
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGOSTIN
MY COMMISSION 6 HH 165705
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EXPIRES: December 144,, 220,226
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Received December 17, 2021
Office of the City Clerk