Yale HerskowitzMIAMI 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 June 24, 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):
oo I am a resident of the City of Miami Beach for six months or longer.
Home Address 4345 Jefferson Ave Miami Beach FL 33140
□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 _
llll 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 City of Miami Beach
Business Address 1700 Convention Center Dr Miami Beach FL 33139
"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
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Yale Herskowitz
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of &physical presence or o online notarization,
23 June 22 Yale Herskowitz
[h[S da/ O[ ,U)y -
_________ (City of Miami Beach Board/Committee Member).
Fl Driver's License X
X
Produced ID
Form of Identification
Personally Known
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#I. CHARLES J. DAGOSTIN ¿%" j &ê wcowwssor s os
j,lhgig¿ Ex RE s: Decem ber 14, 2025
jj& Bonded Thru Notary Public Underwriters
Signature of N9t ap, P?uhi g Charles J. D' gostin
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped