Nicole ComottiCi ty of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
O FFIC E O F TH E C ITY C LERK
Email: BG @m i am i b ea ch i].gov
Telephone: 305.673.7 411
Received January 31, 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.
p {(me \}(]Tes}
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).
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[1J S [[e S, J(Sf9sS-
t am a full-time employee of a business (for a minimum of six months) and l 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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osiess Aaddress. / otLAo f€/G_
"Ownership Interest" means the ownership of ton percent (10%) or more (including the ownership of
10% or more of the outstanding capital stock) in a business.
"Business" moans any sole proprietorship, sponsorship, corporation, limited liability company, or other
entity or businoss association.
Under pey tlties of perjury, J declare that I have read the foregoing document and that the facts stated in it
s , „ olt. 2?
gnature Date
ho.e ou&ni
rited Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
this '_day of January _,20_by
(City of Miami Beach Board/Committee Member).
FL DRIVERS LICENSE X Produced ID
Form of Identification
Personally Known
Ciao 'get
g¿j&;. CHARLEs s. Gosnw ? p""à wvcouussoN w H Ios7os %?pk;is Exes:Doeeon»r 14,202s
%%,j%°' Bonded Thu Notary Public Underwriters
(NOTARY SEAL)
Signature of Notary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped