Sarah Nelson 12/31/231/21/2022
12/31/23 12/31/25
1/21/2022 11/30/2021
1/31/2022
Received January 31, 2022
Office of the City Clerk
1/31/2022
2/1/2022
City of Miami Beach
17 00 C on ven tion C enter Dr ive
Mi am i Beach , Florida 33139
OFFICE OF THE CITY CLERK
Ema il: BC@miamibeachf.gov
Telephon e: 30 5.6 7 3 .7 4 11
Received January 31, 2022
Office of the City Clerk
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STA TE O F FLO RID A
COUNTY OF MI AM I -D AD E
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
}
Home Address
I am a resident of the City of Miami Beach for six months or longer.
l4So N.tedi o vc. Mi@.B«l 331/0
} 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 ot usess _Less_ls_Moc Qa3 t >cos
Business Address_ _5€_ 5Moe
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 _
Business Address _
"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 erjury, I declare that I have read the foregoing document and that the facts stated in it
are true. [J, 9 9 4 ,)
- l l l 'ht
Signature a «w Gu
Printed Name
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or online notarization,
us 29thuay January ,2022 y Sarah Nelson
________ (City of Miami Beach Board/Committee Member).
FL. Driver's License X Produced ID
Form of Identification
Pers9nally,Known
Chaosa ?'goat
g'iii., CHARLES J. DAGOSTN 2$ji$ wüjiji%@se
3Si, si EXPIRES: Decombor 14, 2025 22 ç3Es ",jjj%" Bonded Thru Notary Public Underwriters
(NOTARY SEAL)
Signature of Notary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
X
Received January 31, 2022Office of the City Clerk