Cindy MattsonMI AMI
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@m iamibeachfl.gov
Telephone: 305 .673 .7 411
RECEIVED
APR 14 2023
CITY OF MIAMI BEACH
OFFICE OE TE C/Ty 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):
1ZJ I am a resident of the City of Miami Beach for six months or longer.
Home Address 1700 MERIDIAN AVENUE 403 MIAMI BEACH FL 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).
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
ae"ne mattao 91770%°
Si@nature f Date
CINDY MATTSON
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ~sical presence or online notarization,
ltaay April zo23s,_nAy +altgono
(([[y of Miami Beach Board/Committee Member).
Produce@ID FLD2 M32S-Io]-L3-87)- O
Form of Identification
Signatur of Notary Publi
co y 1gr~s
(NOT ARY SEAL)
Notary. te e, Printed, or Stamped
Notary Publlc State of Florida
L.aura Torres
j» My Commisslon HH 346562
Expires 9/19/2025