Debra SchwartzM IAM I
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
MAR 13 2023
OFFICE OF THE CITY CLERK
Email: BC@miamitbeachtfl.gov CITY OF MIAMI BEAg
Telephone: 305.673.7411 OFFICE or.: THE CITY CLER~
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):
\J lam a resident of the City of Miami Beach for six months or longer.
Home Address st$o [helee DA. /tb 3314o
□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 _
□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 have read the foregoing document and that the facts stated in it
are true. y ll,,,} [f, ] la '·4 cl: 3/3 023
Signature Date 1
Deoa (_ Sly«+f2
Printed Name
NOTARY
Swonso (or affirmed) and subsccibed befoce me, by means ob6hysical presence or online notarization,
.l .at _ Dela Shape12
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(City of Miami Beach Board/C/mittee Member). lj: ... •;:.;.·;,;;,,, CHA D i' .-·.?-'•"' --~-- RLES J. DAGOSTN
Prodoceato F er Ceo-.e fl?%± wrcoivs~iii i«sos 3as ExPREes: December 1a Form of Identification jg Bondea mnu olap," +,2025 Known us! _ votary l ublic Underwriters
(NOT ARY SEAL)
Signatu
Name of Notary, Typed, Printed, or Stamped