Jill ShockettA// A/I 1\/i/V\l E
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl,goy
Telephone: 305.673.7411
Received January 31, 2022
Office of the City Clerk
AFFIDAVIT OF AFFILIATION WITH THE CITY OF M IA M I BEACH
ST A T E O F F L O R ID A
C O U N T Y O F M IA M I-D A D E
l am in com p l ian c e wi th th e affil ia tion requirement of Mi a m i B e ach C ity C o de Section s 2-22 (4), as (ch eck
(/) all that ap pl y): i I am a re sid e n t of the C ity of M ia m i Be a ch fo r six m onths or longer.
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u I ha ve an ow n e rsh ip in te re st (for a m in im u m of six m onths) in a busin ess established in the C ity of
M ia m i B ea ch (fo r a m ín im u m of six m on th s).
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Bu sin e ss A d dre ss ------------------------
o I a m a full-tim e em p lo ye e of a busine ss (for a m in im u m of six m o nths) an d I am based in an off ice or
o the r lo ca tion of th e bu sin e ss tha t is physically lo cated in M iam i Bea ch (fo r a m inim um of six m on th s).
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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.
re tha t I ha ve read the fo re g oing docum ent and that the facts stated in it
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N O T A R Y
S w o rn to (o r affi rm e d ) a n d su bscrib e d be fo re m e, by m ea ns of o physical prese nce or .X. onlíne notarization,
+» ay at January go y
(Ci ty of Miami B e ach B o ar d /C o m mi ttee M emb er ).
FL. Driver's License X P ro d u ce d ID
F o rm of Ide ntifi cation
P9r59nally Known
Chalea DO'goat
Si gn a tu re of N ot ar y P u blic .
Charles J. D'Agostin
N a m e o f N o ta ry , T yp e d , P rin te d , o r S tam ped
'#.. CHARL ES J. DAGOSTIN
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'~": ~\ MY COMMISSION # HH 165705
i} ExPIRs: Decombor 14, 2025
%i{" Bonded Thu Notary Public Underwriters