Rina BassM IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.goy
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):
I am a resident of the City of Miami Beach for six months or longer.
Home Address. (ZS_ w_" gA«th_. M@Li@] fL33o
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 _
y-Hm@SS, J[Hf@Sj-
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 lhe foregoing document and that the facts stated in il
are" [ynut yd_}I 12LL202l
SignatureT Date
na1_ yo
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by ans of s physical presence_or o online notarization,
sll, @or ot Otembr,202\. U4 1 ' SS
X Produced ID #U
Form of Identification
Name of Notary, Typed, Printed, or Stamped
gif#¿, CHARLES I. DAGOSTIN /
f&•· \ MY COMMISSION # HH 1657052 •
z, ¿sS EXPIRES: December 14, 2025
@,jjjj?" Bonded Thru NotaryPublic Underwritors
NOTARY SEAL)
Received December 17, 2021
Office of the City Clerk