Barbara HerskowitzMIAMI B EA C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ail: 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.
-.sass 15 refs AU
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 declare that I have read the foregoing document and that the facts stated in it
are 'fe:Lv00 W\ll ~:1- / _ _? / ;i_ .;i__
Signature Date
hAA'\/MA /tE Stoy
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physi al o
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onlin;;;,:~n, s.3,,Jue.23_,„BA, <
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(City of Miari Beach Board/Committee Member).
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Form of Identification
Name of Notary, Typed, Printed, or Stamped
... CHARLES J. DAGOSTIN }$"jê w cow«s o»ow sos
¿ji},9.sé ERES: Decamber 14, 2025
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