Ronald StarkmanM I AAA I B EAC [
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(a)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
(✓) all that apply):
I am a resident of the City of Miami Beach for six monthsor longer.
Home Address SOD A Or b 2 Age-
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go
p 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 Busi
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
Date �T—
Signature
/ 1
er
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence or ❑ online notarization,
this _ftday of ✓JICJVJUCX� , 20 Z-3 by �y1�� 1.�1 7� Yn ,Yl
(City of Miami Beach Board/Committee Member). 41LAA/F�,".��
Produced ID �r
Form of Identification
Personally Know EXPIRES
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COMMllS&()N
ARY SEAL)
Signature of NcfaryTubliL
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Name of Notary, Typed, Printed, or Stamped �''�a!hll/A,1gEA