Janis GoodMIA\AIBEACH
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
MAR 11 2022
CITY OF MIAM 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):
/ lam a resident of the City of Miami Beach for six months or longer.
ore Aarons (oo. Lacol» A y/2 ha beach
f. 1have 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).
[Jarne (f Pys[mes,S-
[us[mess d(dress
o I am a full-time employee of a business (for a mínimum 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).
[yore f [yg[[es,Ss
[gS/fess ddfesS
"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
"" la.»Ésá 3/rola.o22
Signatur?"- Date
hais Led
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of~ysical presence or a online notarízation,
»/2,a@ H a2M, _Jo/s 6oo)
(City of Miam i Beach Board/Committee Member ).
X eoaoeeao / D ue s Lio se
Form of Identification
o all Know
.È»., CHARLES J. DAGOSTIN /lJl:.•"~\ MY COMMISSION# HH 165705 iwi ·a? i, „;ki EXPIRES: Dece mber 14, 2025
%};;$$ ponded Tu Notary Public Underwriters
i i' _
Signa
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped