James SilversM IAM I BEA C H
City of Miami Beach
17 00 C onventio n C enter Drive
M ia m i Beach, Florida 33 13 9
O FFIC E O F TH E C ITY C LERK
Email: BC@miamibeachfl.gov
Telepho ne: 30 5 .67 3 .7 4 11
RECEI VE D
FEB 11 2022
CITY OF M IAM I BEA CH
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):
>( I am a resident of the City of Miami Beach for six months or longer.
or e Aware.. 27q M , HB l b_
□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 _
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 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.
Signature
y, I declare that I have read the foregoing document and that the facts stated in it
e ]a Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ~sical pr~sence or o online notarization,
so./sap.222LS S7US
x (City of Miar 1ch Board/Committee9Member).
Ee ..2
Signatu
.g#È#., CHARLES J. DAGOSTIN ::,¡~;¥ MY COMMISSION HH 165705
$3;± ¿é EXPIRES: December 14, 2025
ífjyjj Bonded Tu Notary Public Undenwrhors
(NOTARY SEAL)