Tiffany LapciucRE CE I VE D
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
OF_ MIAMI BEACH
I am in compliance with the affiliation requirem ent of Miami Beach ct'dé séiíióris 22 (4)as (check
(/) all that apply):
✓I am a resident of the City of Miami Beach for six months or longer.
Hom e Adare. +l65 NW Medan @eno_ L!„OLÉ.334o
FEB 3 2022
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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lam a full-time emp loyee of a business (for a minimu m 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).
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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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
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Signature 7 Date
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NOTARY
Sworn to (or affirmej) and subscribed before me, by means of physical presence or,)6nl ine notarization,
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(NOTARY SEAL)
Name o otary, Typed, Printed, or Stamped : CHARLES J. DAGOSTIN $$e. "
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zj,Nd.isé Ex REs: December 14, 2025
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