Martha Baker 12/31/23Martha Baker 1/20/2022
City Commission
12/31/25
1/21/2022 N/A
1/25/2022
Received January 25, 2022
Office of the City Clerk
1/25/2022
1/26/2022
25th Jan
City Mi ami leech
1700 Conn#ton Conter Drive
Miomi Be &h, florida 3313%
OFFICE OF THE CITY CLER K
Email: Ggrniamibe ch.goy.
Teleph on e: 305.6 73.7411
AFEIDAVII OF AFFILIATI ON WITH THE CITY OE MIAMI BEACH
Received January 25, 2022
Office of the City Clerk
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am In com p lian ce with the affil ia tion requirement of Mlaml Beach Clty Cod e Sections 2-22 (4), as (check
(/) all tha t apply):
lam a resident of the City of Mlaml Beach for sb months or long er.
Hom e Ada n«. Ju85 CLEVu0. R. h. 321fl r 7
a I have en ownershlp interest (for a mi nim um of slx months) ln ea business established in the City of
Mleml Beech (for a minimum of shx mon ths).
[gr9f [styg]raspo
3tg@lpg@ ddfg}-
a {am ea full-time employe e of a business (for ea minimum of six mon ths) and I am beased In an office or
other locat ion of the busl ness tha t ls physlcal ly located In Miaml Beach (for a mlnlmum of slx mon ths).
fags gf itgglf@
3tyg[pagg dtdfe@
"Ownershlp interest" means the ownership of ten percent (10%) or more (including the ownershlp of
10% or more of the outstanding capital stock) hn a bus/less.
"Business" means any sol o proprietorship, sponsorship, cor pora tion, lim ited llabllty comp a ny, or other
entity or business essoclatlon.
Under penaltles of perj ury, { declare that l have read the foregoing document and that the facts stated In lt
are true., „/,,4, y 141] p J
sea "{ellle la- oc 2'1,ol
dt rd 1 £4et, Kr-
Printed Name
N O TAR Y
Swom to (or affirmed) and subscrlbed before me, by means of physlcal press line qtar izatlon,
»? .a"nan .a??» --. I[Pf us-l-
(City of Mlaml Beech Board/Committee Member).
X Produced 10 FL. Driver's License
Form of {den tlfica tion
• Personally Known
Ciao 'je
Signature of Notary P?be Charles J. 2'Agostin
Name of Notary, Typed, Printed, or Stamped
(N O TARY SEAL )
gjig. CHARLES J, DAGOSTIN £$ ";; w co»M us1 oN HHu 16s7os
zj,9.j; EREs: Decam ber 14, 2025
"y é" Bonded Tru Notary Public Underwriters
Health Advisory Committee 1/2022
X
Received January 25, 2022Office of the City Clerk