Ben MostkoffMIA] H
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
AEFIDAVII OF AEEILIATION WITH THE CITY OF MIAML BEACH
ST A TE OF FLORI DA
COUNTY OF MaDa"°
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check(✓) all that apply):
0' I am a resident of the City of Miami Beach for six months or longer.
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 month s).
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).
"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 perj ry, I declare that I have read the foregoing document and that the fact s
stated in it are tr ·l 1
1/10/2022
Signat
Benjamin J. Mostkoff
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or□online
notarization , this_'0_day of"UaY ,20??_y Benjamin Mostkoft
________________ (City of Miami Beach Board/Com mittee Member).
X Produced ID FL Driver's License ----------------- Form of Identification
Personally Known
Cito v'ge (NOT ARY SEAL)
Signature of Notary Public
Ch ar le s J. D'A go stin
Name of Notary, Typed, Printed, or Stamped .iü., CHARLES J. DAGOSTIN ¿$j; wcouussroN «w is7os
:,94,¿is$ EXPIRES: Docmber 14, 2025 ¿á Bonded Thu Notary Pub lic Underwrit ers iris