Jason KosloweMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33134
OFFICE OF THE CITY CLERK
Email: lGcr�nt<xrrrif�Gci7fl.c�crr
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):
M 1 am a resident of the City of Miami Beach for six months or longer.
Home Address 525 West 28 Street
❑ 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 declare that I have read the foregoing document and that the facts stated in it
are fr�r Re-Appt 1/6/23
Date
Jason Koslowe
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or o online notarization,
this — day of ^u , 20 by
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
ersonall/y Known
Signat e of Notary Public
Name of Notary, Typed, Printed, or Stamped
gti�se,nr� ANTOINETH L SALMON
'��1 Notary Ptr6He Efate of rtorfda
Commission q HH 208741
or rz: My Comm. Expires pec 15, 2025
Bonded through National Notary Assn.
(N(5TA S_ A )