Elaine RodenMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf.gov
Telephone: 305 .673 7411
RECEIVED
JAN 13 2023
CITY OF MI A MI BEACH
OFFICE O E THF CITY CL ER
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST A T E O F F LO R ID A
C O U N T Y O F M IA M I-D A D E
I am in co m p lia nce w ith the aff iliatio n requirem ent of M iam i Beach C ity C ode Section s 2-22 (4), as (check
(/) all tha t apply):
□I am a resident of the C ity of M ia m i Beach fo r six m onths or longer.
H o m e A dd ress _
□I have an ow ne rship interest (fo r a m inim um of six m onths) in a business established in the C ity of
M ia m i Be ach (fo r a m inim um of six m onths).
N a m e of Business _
[[I /[e s,, J (]res5
0 I am a full-tim e em p loyee of a business (fo r a m inim um of six m onths) and I am based in an office or
othe r locatio n of the busine ss that is physically located in M iam i Beach (fo r a m inim um of six m onths).
N a m e of Busine ss Miami Beach Watersports Center Inc
Busin e ss A ddreg 0500 Indian Creek Drive, Miami Beach 33141
"Ownership Interest" means the ownership of ten percent (10%) or more (including the ownership of
10% or m ore of the outstanding capital stock) in a business.
"Business" means any sole pro prietorship, sponsorship, corporation, limited liability company, or other
entity or business association.
I de cla re that I have read the fo regoing docum ent and that the fa cts stated in it
1/13/2023
S ig na ture
Elaine Roden
D ate
Printe d N a m e
N O T A R Y
Sw orn to (o r aff irm ed) and subscribed befo re m e, by m eans o/~sical presence or□online notarization,
o« a03d9[23s E[Are {le-u
Pr o duce d ID
(Ci ty of M[ami Beach Board /C om mi ttee M emb er ).
bhtee's l-'ce>e .gjig, CHARLES J. DAGOSTN
? b ",< MY coMMIssIoN # HH 16570s
j,hk.#; ExPREs: December 14, 2025
f;jg Bon ded Thru Notary Public Underwriters
(N O T A R Y S E A L)
Signa
N a m e of N o tary, T ype d , Printed , or Sta m ped