Laurence MoserM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
FEB 3 2022
CITY OF M IAM I BEA CH
O FFIC E O F TH E C ITY C LERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STA T E O F FLO R ID A
C O U N T Y O F M IA M I-D A D E
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
0 3 that apply):
/ am a resident of the City of Miami Beach for six months or longer. s A«sr. H+lé7 h end ['Ai Beach , [ 33l'%°
J i have an ownership interest (for a minimum of six months) in a business established in the City of
EE~ ::es • éi i! fo ijz,f 3//o
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 Bead, (for a minimum of six months).
[[are tf Py[[meSi
[1J s][%S S (](]fr%S i-
"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 p alties of perjury, I declare that I have read the foregoing document and that the facts stated in it
e4 .. 8/0/0000
t%e ose- "
Printed Name
NOTA RY
Sworn to (or affirmed), and subscribed before me, by means of o physical presence o~ine notarization, a.a/deep2. LA4Ree [@Ser
(City of Mami Beach Board/Committee Member).
roaoceao ft_.[Rex _ e se
Form of Identification
P7on y Known
L
.gifz¿, CHARLES J. DAGOSTN $"êj"? W co»IssloN # HH 165705
Èj,bk,&j xRes: oocam»or 14,2025
"7z.$ Bonded Thru Notary Public Underwriters
ii
(NO TARY SEAL)