Ricardo LopezMIAMI BE
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
Serves on the the HPB, Exempt from
Residency Requirements
Received February 10, 2022
Office of the City Clerk
AFFID AVIT OF AFFILIATION W ITH 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):
o I am a resident of the City of Miami Beach for six months or longer.
Home Address 4291S12 ST, Miami, FL-33134
o I have an ownership interest (for a minimum of six months) in a business established in the City o
Miami Beach (for a minimum of six months).
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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).
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"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,/declare that I have read the foregoing document and that the facts stated in it
are true. lì
1
•
2022-02-10
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or online notarization,
o "a , feruan o?4 Rcardo torez ------' __ y _
(City of Miami Beach Board/Committee Member).
FL. Drivers License X
Produced ID
Form of Identification
Personally Known Citata 7'geti
Signature of Notary Public
Charles D'Agostin
, CHARLES J. DAGOS'TIN
/~~-~\ MY COMMISSION # HH 165705 ¿i : ±¿, ¿sg EXPIRES: December 14, 2025
};z5 ponded Tu Notary Public Underwriters iii»
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped