Heidi TandyMI A MI B
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
R ECEI VE D
FEB -7 2022
Email: BC@miamibeachfl.gov CITY OF MIAMI BEACH
Telephone: 305.673.7411 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 I am a resident of the City of Miami Beach for six months or longer.
Home Address 5500 Collins Ave., 1801 Miami Beach FL 33140
□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 of Business _
Business Address _
□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 perjury, I declare that I have read the foregoing document and that the facts stated in it
are true. a l tan}y 02/07/2022
Signature
Heidi Tandy
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or ,Wn1ine notarization,
.7 a [ele1a22 he di ID]
Y Produced ID
(City of Mi am i Beach Board/Committee Member). FL. DoiVKs Ao'so ## ,-~;¡•·-~\ CHARLES J. DAGOSTIN itji, ¿si MY COMMIssIoN # HH 1os7os
8%q$$%' EXPIRES: Decomber 14, 2025 '1"" Bon ded 'Thru Notary Public Underwriters
(NOTARY SEAL)
Signat
Name of Notary, Typed, Printed, or Stamped