Rosary FaleroM IAM I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
FEB 8 2023
CITY OF 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
(/) all that apply):
121 I am a resident of the City of Miami Beach for six months or longer.
4550 Pine Tree Drive, Miami Beach, Fl. 33140 Home Address _
□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 _
o 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 associati .
eel re that I have read the foregoing document and that the facts stated in it
2/1/23
Signatur
Rosary Plana Falero
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
mas "aay or _tong,2oa ». ( qa-no Fcd o2
________ (City of Miami Beach Board/Committee Member).
PL_ Ory@ Ln£ Produced ID
Form of Identification
_ Perso~----
sionatore of Nay uni
Name of Notary, Typed, Printed, or Stamped