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Gabriel Paez! I VIdAMI BEACH 4101114113 City of Miami Beach DEC 01 2021 1700 Convention Center Carve Miami Beach, Florida 33134 CITY OF MIAMI BEACH OFFICE OF THE CITY CLERK OFFICE OF THE CITY CLERK Email: fl.gov Telephone: 305.673.741 1 AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check (✓) all that apply): © I am a resident of the City of Miami Beach for six months or longer. Home Address: '100 t_t A cvL .yy � LAA ❑ 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 (109,66) 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 staid in -it are tru � 1 12- te t Signatur / Date Printed Name