Tiere Hessert Sep 2022MIAMI BEACH
City of M iami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICF OF THE CITY CL E RK
Email: BC@miamibeachf.gov
Telephone: 305.673.7411
RECEIVED
AUG 16 2022
CITY O F M IAM I BEA C H
OFFICE OE THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
/ 1am a resident of the City of Miami Beach for six months or longer.
Home Aa@res. (ooo Po_he_ Dr., url So-1, ±iamni Beach F 3337
7
I have an ownership interest (for a minim um of six months) in a business established in the City of
Miami Beach (for a minimum of six months).
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iama fuii-time employee of a business (for a minimum of six months) and ! am based in an office or
other location of the business that is ph ysical ly located in Miami Beach (for a minimum of six months).
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H g/fess, J(]Jr?SS-
"Ownership Interest" means the own ership of ten percent (10%) or more (including the own ership 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 "su ml hrss , 2o>l
sac k " „J"#
Ter« Hg geut
Printed Name
NOTARY
Sworn to ( or affirmed) and subscribed before me.by means of °f!(;"':!I prese']':: or o online notarization,
/5f a August.22 Jcc <5se-f
(City of Mlii Beach Board/Committee Member).
ft uce s Lien sc X Produced ID
Form of Identification
gs;g., HARLEs J. DAGos
5 bd h,¿ MY co ussI oN + HH 1657os
±,Nd,is; ExP REs: December 14, 2025
~?" Bonded Tru Notary Public Underwriters
(NOT ARY SEAL)