Cheryl Jacobs 12/31/23CITY COMMISSION
1/20/2022
12/31/23 12/31/23
1/21/2022 -
2/2/2022
Received February 2, 2022
Office of the City Clerk
2/2/2022
2/3/2022
2/2/2022
2nd Feb
M IA M IB EAC
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
Received February 2, 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):
X lam a resident of the City of Miami Beach for six months or longer.
Home Address 20 Islan d A ve Apt 707 M iam i Beach FL 33139
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).
[p3[% (f [11[PS3
P[][[S , J[[F j _
u 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 localed in Miami Beach (for a minimum of six months).
Name of Business _
[JS1[]@ (HTS--
"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.
n
Und
are t
lare that I have read the foregoing document and that the facts stated in it
1/27/22
Sign
Cheryl H to
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of a physical presence or Xonline notarization,
27thaa ar January , 20 22 by Cheryl Jacobs
_________ (City of Miami Beach Board/Committee Member).
FL. Driver's License X Produced ID
Form of Identification
B29r90ally Known
Chaea ?'peat,
:2, CHARLES J. DAGOSTIN :'~¡>!\·~·- . ¿ii ¿? MY COMMISSION # HH 165705
3; ¿ EXPIRES: December 14, 2025
jjfê Bonded Thu Notary Publie Underwriters
(NOTARY SEAL)
Signature of Notary Public
Charles J. D'Agostin
Name of Notarv. Tvoed. Printed. or Stamped
X
Received February 2, 2022
Office of the City Clerk