Ana Rabelo Sep 2022MIAMI BEACH
RECEIVED
City of Miami Basch JUL 21 2022
1700 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICE OF THE CITY CLERK
Email: BC(Qrnjan1oeachfl 4ov
Telephone: 305.673.7411
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):
t/ I am a resident of the City of Miami Beach for six months or longer. ' n
Home Address -�Jc) crc� l.g rpt ikP�-. �,vb S— tic- h� Jl �. 3 313.E
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 pmalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
aree. -�
I ure Date
Arts 1L Ar �l
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of hysical pr/esence or r, online notarization,
this�l day of I C c 20?�)by
Produced ID
(City of Mia i Beach Board/Com ittee Member).Fl�o,
CHARLES J.DAGOSTIN(./eer ��MY COMMISSION # HH 165705/JS l tf '` C ,a• EXPIRES: December 14, 2025
Form of Identification ►F,' BmdeamruNof< PublicUnde,writers
Personally Known
2 (NOTARY SEAL)
Sig a of ry P is
Name of Notary, Typed, Printed, or Stamped