Jason Koslowe 12/31/2312/31/23 12/31/27
1/25/2022 N/A
1/25/2022
Received January 25, 2022
Office of the City Clerk
1/25/2022
1/26/2022
C ity of Miami Beach
1700 Convention C enter Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miarnibeach fl.go.
Telephone: 305.673.7411
Received January 25, 2022
Office of the City Clerk
A F F ID A VI T O F AF FIL IA TI O N WI TH T H E CI T Y O F MI AM I B E A C H
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance wi th the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(✓) all that apply):
f 1am a resident of the City of Miami Beach for six months or longer.
(2 /2 f" fy , } , .
Home Address !iv' Aves ' 1)'
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 _
{I S,[[SS, ](Fes}.
"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.
of perjury, I declare that I have read the foregoing document and that the facts stated in it
l Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence orX online notarization,
us 25thuay or January , 20 22 by Jason Koslowe
_________ (City of Miami Beach Board/Committee Member).
FL. Driver's License X Produced ID
Form of Identification
Personally Known
Ciao, 'peto
Signature of Notary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
emmeeee e p2 7e! ,. .ü . CHARLE S J. DAGOSTIN /f~¡•·~\ MY COMMISSION # HH 165705 ii,, „ii EXPIRES: Decamber 14, 2025
?{gá$ ponded Tru Notary Pub»lie Underwriters
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Received January 25, 2022Office of the City Clerk