Pamela MayerMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(Wmiamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
JAN 30 2023
flL. �- L.. , V L;J
JAN 30 2023
CITY OF MIAMI BEACH CITY FF MIAMI
BEACH
OFFICE 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):
I am a resident of the City of Miami Beach for six months or longer.
Home Address a30 l�(�s q t� �7J /,pro 1 QAC /� FL 3/ -3
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 B
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 (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.
`Ljn,der penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
Signature Da
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of%x, physiicalal�presence orr�❑ online notarization,
this day of �� , 20�-3 by�yT
K Produced ID
(City of Miami Beach Board/Committee Member).
CHARLES J. DAGOSTIN
FF.
#: MY COMMISSION # HH 165705
Form of Identification ,;• EXPIRES• December 14, 2025
P o I Know off; ars
Y „os v Bonded Ttru Notary Public Undmwft
(NOTARY SEAL)
Signature o ry Pwaic
Name of No ary, Typed, Printed, or Stamped