Sara de los ReyesCity 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
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) II that apply):
r l am a resident of the City of Miami Beach for six months or longer.
Home Address l goo-r�-a-.� �i �E u� ;�%�i/ //�i�,rwl�,+� 3.31 V
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
❑ 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 declar.� that I have read the foregoing document and that the facts stated in it
are true. "
A C 44,- 7A,"I'�.IX,^ — h, /.;–) _,-3
Siqnature f Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means ofysical presence or ❑ online notarization,
I K_
this L day of � , 20��--Sby /- S drveS
(City of Miami Beach Board/Committee Member).
17PU ••., CHARLES J. DAGOSTIN
At
� MY COMMISSION it HH 165705
Produced ID EXPIRES: December 14, 2025
Form of Identification Bonded Thru Notary PubkUndermiters
771
ty Known
(NOTARY SEAL)
Sign o u M is
Name of Notary, Typed, Printed, or Stamped