Benjamin MostkoffB/1 A\.\l
City of Miami Beach
1700 Convention Cenler Drive
Miami Beach, Florida 33139
RECEIVED
JAN 09 2024
CITY OF MIAMI BEACH
OFFICE OF TF CIT CLERK
OFFICE OF THE CITY CLERK
Email:. BC@miamibeachf.gov
Telephone: 305.673.7411
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):
«{ lam a resident of the City of Miami Beach for six months or longer.
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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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a lam a full-time employee of a business (for a minimum of six months) and l 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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"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.
-have read the foregoing document and that the facts stated in it
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Signature
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Date °
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ~I presence or online notarization,
2.say «_Mack 2o23 o, Ego> T [lsraf
(City of Miami Beach Board/Committee Member).
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Name of Notary, Typed, Printed, or Stamped