Benjamin MostkoffMIA0/BEA
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf.gov
Telephone: 305.673.7411
RECEIVED
JUN 30 2023
CITY OF MIAMI BEACH
OFF ICE OF THE CITY CLERK
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):.
«( lam a resident of the City of Miami Beach for six months or longer.
ome A@ares. /70o lake€ Drat, /"hanu ~tc, 1. 33//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).
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Business Address ------------------------
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" means any sole proprietorship, sponsorship, corporation, limited liability company, or other
entity or business association.
Signature
aiol 1 Msor,
-have read the foregoing document and that the facts stated in it
/so 24, Ao23
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of 4cal presence or online notarization,
.aay Mac4 2oz7 » leg » T [hsraf
(City of Miami Beach Board/Committee Member).
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Signature of Notary Public 17cdac s f€nu4w!
Name of Notary, Typed, Printed, or Stamped