Magui BenitezM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miam i Beach, Florida 33139
O FFIC E OF THE CITY CLERK
Email: BC@ miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
FEB 1 7 2022
CITY O F MIAMI BEACH
OFFICE OF THE CITY CLER K
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLO R IDA
C O UNTY O F MIAMI-DADE
I am in compliance with the affiliation requirement of M iami Beach City Code Section s 2-22 (4), as (check
( ✓) all that apply):
y I am a resident of the City of M iami Beach for six months or longer.
Hom e Addre ss. 'Z5? I'Est //? lp. nL3st3q
o I have an ownership interest (fo r a m inimum of six months) in a business established in the City of
M iami Beach (fo r a m inim um of six m onths).
Name of Business _
Business Address _
o I am a full-tim e em ployee of a business (for a m inimum of six months) and I am based in an office or
other location of the business that is physically located in M iami Beach (fo r 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. ¿ . -~/ /. . / 22,=- , <y_a
Signat uíe Date " •
Printed Nam e
NO TARY
Sworn to (or affi~~d) and subscribed befo re m e, by m eans o~hysical presen~e or o online notarization,
ss/Eso»la uwep e.22, ha, [eu_tez
(Ci ty of Mi 8pi Beach Board /compi ttee M ember ).
X ro aocaao / [e/A S / e9 s;#. CHARLES J. DAGOS TIN ,~r:¡,r. -\'~h MY COMMISSION# HH 165705
ii, ii EXPIRES: December 14, 2025
;$' ponded Tru Notary Public LUderwors
i
(NOTARY SEAL)