Elaine Roden 12/31/2212/31/22 12/31/29
1/21/2022 11/1/2021
1/21/2022
Received January 21, 2022Office of the City Clerk
1/21/2022
1/26/2022
MIAMI BEACH
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
Received January 21, 2022
Office of the City Clerk
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.
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□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).
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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, I declare that I have read the foregoing document and that the facts stated in it
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Signature Date ' '
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Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me,Py,means of }physical P95%)e or online notarization,
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________ (City of Miami Beach Board/Committee Member).
FL Driver's License X Produced ID
Form of Identification
Personally Known
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(NOTARY SEAL)
Signature of Notary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
X
Received January 21, 2022Office of the City Clerk