Barbara Herskowitz Sep 2022MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(@miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
JUL 22 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
(J) all that apply):
6 I am a resident of the City of Miami Beach for six months or longer.
Home Address 1-1345— /4 "
❑ 1 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
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 tru i —old,
^ dZ
Signaturb Date
(MAN � Vs�jw►-�
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me by means
of yphyjsical presence or ❑ online notarization,
thi>g day of �L(/C' 209�y / �/� A /s/e/. �t 2
(City of Miami Beach Board/Committee Member).
CHARLES J. DAGO,
_ Produced ID MY COMMISSION#HE
,Q� rs Hall Know Form of Identification�Po= EXPIRES: December 1�, .:
/� i F„ Bonded Rau Notary Public Undo..,;.,
V; CHARLES J. DAGOSTIN
' *: MY COMMISSION 0
Sign e of ry Public '' EXPIRES: December 14,2025
�''F7is d�qP r Bonded Ttw Notary Public Underwriters
Name of Kotary, Typed, Printed, or Stamped