Tomas Salerno1\1/\0 \l
City of Miami Beach
1700 Convention Center Drive
Miam i Beach, Florida 33 139
OFFICE OF THE CITY Cl.ERK
Email: BC@miamibeachfl.gov
Telephone: 305.673,7411
RECEIVED
FEB 72023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLE
AFFIDAVIT OF AFFILIATION WITH TH E 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):
) lam a resident of the City of Miami Beach for six months or longer.
Home Address5 South Hibiscus Drive, Miami Beach, FI 33139
□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).
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p 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).
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"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 true.. 2 Zf Febru ary 7. 2023
Signature
Tom as Antonio Salern o
Date
Printed Name
NOTARY
Sworn to (or amrJ .. e.•.di·a· nd subscribed before me, by means. 0. to physical pr·e·· s.e~nce or o online notarization,
me 7d.av \hell2ya0a3. co«ao Skea, MD
(City of Miami Beach Board/Committee Member).
Produced ID D._Lc #S46-got-44-0ll._o
Form of Identification
Signat&
l_ry G o02lz2.
Name of Notary, Typed, Printed, or Stamped
,,{JNA GONE2,
ota9Will8G Eilba
Commission # HM 192395
My Comm. Expires @ct 31, 2025
8onded through National Notary Assn,