Gayle Durhamx
114' 1 AM I B EAC H
City of Miami Beach
1700 Convention Center Dive
Miami Beach, Florida 33139
RECEIVED
DEC 01 2021
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFI(.F- 0P THE CITY CLERK
Email: 13C,@,rni ii rev_
Telephone: 305,673.7411
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):
n%o
A I am a resident of the City of Miami Beach for six months or longer.
Home Address: 1455 WEST AVENUE, APT 804,33139
❑ 1 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:
r_1 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 (1091o) 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 pedury, I declare that I have read the foregoing document and that the facts
j
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J_in Xit-1, true,
DEC 1, 2021
Signaturk Date
GAYLE DURHAM
Printed Name