Alyssa Baumgarten Sep 2022M I A/\A, I B EAC H
City of Miami Beach WINED
1700 Convention Center Drive
Miami Beach, Florida 33139 —6 2022
OFFICE OF THE CITY CLERK OCTM
Email: BCP_miamibeachfl.gov r ' br MIAMI BEACHTelephone: 305.673.741 1 fCE 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):
o," I am a resident of the City of Miami Beach for six months or longer.
Home Address `A-,% TI i `re- �A vcv . k 9'e".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
❑ 1 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 (109/6) 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
aretu�'. �?
Signature Date
Ads s`''
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o physical
this qay of �2 byl
Produced ID
(City of Kiami Beach Board/Committee Member;
Form of Identification
_ P �o ally Known
Sig nat orzlp*
Publi
Name of N ary, Typed, Printed, or Stamped
or ❑ online notarization,
a �"o,A)
(NOTARY SEAL)
CHARLES J. DAGOGTIN
MY COMMISSION # H! i 165705
r,_ z
EXPIRES: December 14, 20,25
Bonded Thru NoWy Public U tdanvriler9
(NOTARY SEAL)