Daniel RoblesMIAMIBE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
RECEIVED
MAR 3 2023
CITY OF MIAMI BEACH
OFFICE Or "4F 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):
@ I am a resident of the City of Miami Beach for six months or longer.
Home Addres838 Collins Ave Apt. 6E Miami Beach FL 33140
0 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 BlackOak Capital Group
Business Address 5838 Collins Ave Apt. 6E Miami Beach FL 33140
□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 association.
Under penalties of perjury, I declare that I
are true. • o4,, » a.t. J. {of @-
ave r ad the foregoing document and that the facts stated in it
2/27/2023
Signature
Daniel Robles
Date
.-
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
l ay oor .2o3 y Ohl WA bl{
_________ (City of Miami Beach Board/Committee Member).
yy vto1 Produced ID Ut!f-f I entification Personally K n - Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped