Steffany LancettMIAMIBEA H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl_gov
Telephone: 305 .673 .7 411
Received February 27, 2022
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.
Home Address 158 S Shore Dr. Apt. 4, Miami Beach FL, 33141
o 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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are true.
2/27/2022
Signature
Steffany E. Lancett
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or u online notarization,
. 27th February 20 22 b Steffany Lancett
[[[(là/ [. ')y
(City of Miami Beach Board/Committee Member}eemeeeeeeeeeeemse,$
4. CHARLES J. DAGOS'TIN
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(NOTARY SEAL)
Signature of N9tap Pub[ç Charles J. D' göstin
Name of Notary, Typed, Printed, or Stamped