Dana Wolpert MartorellaCity of Miami Beach
1700 Convention Center Drive
Miami Bech, Florida 33139
ORCE OF THE CI CLERK
Email EC@m.9m234%¥
RECEIVED
MAY 24 2073
CITY OF MIAMI BEACH
OFFICE TF L,« Crv CLERK
AFFIDAVIT OE AFFILIATION AITH THE crr OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DAD E
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply).
1am a resident of the City of Miami Beach for six months or tonger.
Home Address l,0 ht [ Pr, Mi so,v 349
[ Ihave an own ersh ip int ere st (for a minimum of six months) in a business established in the City of
Miami Beach (for a minimum of six months).
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Py,1fP,, l(}]fP?«,i.or-
DI 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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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" me ans any sole proprietorship, sponsorship, corporation, limited liability company, or other
entity or business association
Und er penalties of perjury , I declare that I have read the foregoing docum en t an d th at the fact s stated in it
are true/ \ a a } ._. _ _ 5 /2·/2>
Si gnature fn
Do A. vol«t Marlor«.
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or r online notarization,
mus ?':'cay 1.07n_2o2_oy a.a_rook IUcLpuni
(Cily of M iamu Beach Board/Comm itt ee Memb er)
Le. P rod uce d [__nL Drury» rniA
Form of Identification
Personally Kown
Name of Notary, Typed Printed or Stamped