Mike GibaldiM IA M 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 .7 411
RECEIVED
MAR -7 2022
CITY OF MIAMI BEACH
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
!g\"at av»
V I am a resident of the City of Miami Beach for six months or longer.
Home Address 4780 Pine Tree Dr, Apt 1, Miami Beach, FL 33140
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 ------------------------
n/a
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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"
H3[s[fess (]resS
"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. ')ii Çbald; 3-5-22
-------------- Signature
Mike Gibaldi
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o~hysical presence or□online notarization,
o.S_ »AH .O-2 Le ,Au ¿
________ (City of Miami Beach Board/Committee Member).
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], Form of Identification
Pers onally Kn own
., CHARLES J. DAGOSTIN
,-~~~>!'"~\ MY COMMISSION# HH 165705
3±; :; EXPIRES: December 14, 2025 :%., S ' ·ters ¿s Bonded Tu Notary Pubic Underwrt ....... ,,,
(NOTARY SEAL)
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