Liza SamuelM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
M ia m i B ea ch, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@m iamibeachfl.gov
Telephone: 305.673.7411
AEFIDA VII OF AEEILIATION yIIH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF _
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (ch8ç () al l that apply):
yí , a resident of the City of Miami Beach for six months or longer.
D 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).
D 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).
"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.
d December 23, 2021
Date
Liza Samuel
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of [Physical presence or online
oso.so .22 a.U te.her_ ?L L4 S/444
X Produced ID 7) (City of Miami B¡ach Board/Committee Member). F- hu y ,ese
Form of Identification
(NOTARY SEAL)
Name of otary, Typed, Printed, or Stamped
y CHARLE S J. DAGOSTIN t:oo:~ MV COMMISSION t HH 165705
i%, çs¿ EPIRES: December 14, 2025
fjiyç" Bonded Tu Notary Publie hndenwrors