Matthew Land 12/31/2312/31/23 12/31/23
Received February 8, 2022
Office of the City Clerk
1/21/2022 12/21/2021
2/8/2022
2/8/2022
2/9/2022
MI A MAIBE A CH Received February 8, 2022
Office of the City Clerk
City of M iam i Beach
1700 Convention Center D ive
Mi a mi Bea ch , Florido 33 13 9
OFFICE OF THE CITY CLERK
Email. BC@mnamibeachf gov
Telephone: 305 673 7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply). e I am a resident of the City of Miami Beach fo r six months or tonger.
Home Asare ._1tGo La«col P,_l.37,333f
o I have an ownership interest (for a minimum of sx months) in a business established in the City of
Miami Beach (for a minimum of six months).
[y3mm@ Pf P1,obi
Pp1,1mes,S (]HfeSi
a 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).
[}arfe tf [y1meSi
]JS[PS ](feSb
"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.
rjury, I declare that I have read the foregoing document and that the facts stated in it
213/22
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or Xonline notarization,
pu l hl4 a lebruary 2o22_by
(City of Miami Beach Board/Committee Member).
FL Driver's License X Produced ID
Form of Identification
Personally Known
Ciao. 'get
"32.. CHARLES J. DAGOSTIN $$"j ê, wrcouwssor isros
j,a!9.ijé ExPREs: Decom er 14, 2025
"íf;&" Bonded Thru Notary Public Underwriters
(NOTARY SEAL)
Signature of Notary P ubl ic
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped
X
Received February 8, 2022Office of the City Clerk