Maria AlgarraM 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 7411
RECEIVED
APR 27 2022
CI T Y OF MIAM I B E A CH
OFFICE OF TE 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):
11 I am a resident of the City of Miami Beach for six months or longer.
Home Address 833 West Ave, Miami Beach, FL
IMI 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 Clean This Beach Up Org
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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are true.
Signature 2i- 04/27/2022
Date
Maria Jose Algarra
Printed Name
NOTARY
>
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
2 l ap ,] a s02 » 1ALA JOSE AL6eRÇ4
(City, of Mi ami Beach Board/Committee Member). F L uc s le Produced ID
, Form of Identification
Peysonally Known
Signa
sgji%., CHARLES J. DAGosTN ,è h; MY COMMISSION # HH 165705
%%j, çsi EXPIRES: December 14, 2025
·%ji?" Bonded Thu Notary Public Underwriters
(NOTARY SEAL)
, Typed, Printed, or Stamped