Natacha FernandezM IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
RECEIVED
FEB 1 7 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CIERK
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):
V I am a resident of the City of Miami Beach for six months or longer.
o » uore. _;22 Calno khe apf 5 Aau@_leacl, FL 319
□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.
ry, I declare that I have read the foregoing document and tha the facts stated in it
2,·2
Date
NOTARY
Sworn to (or affin;&nd subscribed before me, by means o~ysical pres ence or online notarization,
«./2./6 ozs2M./A hala /valez
(City_ of Miami Beach Board/Committee Member).
/ /kens Ae>se x Produced ID
Form of Identification
Pe?ónally Known
.s. CHARLE S J. DAGOS TIN $ Cj$"f; wcoussioii» nos
êij, lle.is$ xPREs: Decambor 4, 2025
?5$g Bonded Thru Notary Publi c Underwors
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(NOTARY SEAL)