Amy LitosM A MIBEA CH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ai l: BC@miamibeachfl_gov
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 650 West Ave. #1802 Miami Beach, Florida, 33139
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 -------------------------
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 decl r that I have read the foregoing document and that the facts stated in it are"ab 01/02r22
--------------- Sign ature Date
Amalia Litos
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by m ans of o physical presence or o online notarization,
o 2a,a)299a 22, ·/o
'K
Ci y o MD. i Beach Board/Committee Member).
coa«eso / )icuL_y_ea
Form of Identification
ers nally Known
Sign %:.. CHRLÈS ü. DAGOSTIN ê" j wcouussIoN # H 165705
j,ft&$ xens: Decenter 14,2025
8;ks Bonded Thu Notary Public Underwriters
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