Diane KleinCity of Miami Bea ch
)700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CIERK
Email: BC@miamibeachfL.gov
Telephone: 305.673.741I
RECEIe
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AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
pl lam a resident of the City of Miami Beach for six months or longer.
Home Address 765 South Shore Dr Miami Beach FI 33141
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
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n lam 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 own ership of ten percent (10%) or more (including the own ersh ip 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
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Signature Date
Diane Klein
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ph ysical presence or tu online notarization,
his l_ aay or_h)nor.202y
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
X_ Personally Known < C
e of Notary Publj
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MELISSAL. DORE
MY CO$S#ON $ H 229154
EXPRES: .Ju 1, 2026
(NOT ARY SEAL)