Karen RivoNA I AM' BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
DEC 012021
OFFICE OF ME Cl f CLERK
Email: i3riminiitseart.crv, CITY OF MIAMI BEACH
Telephone: 3011,673.7411 OFFICE OF THE CITY CLERK
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),
ars (check (-/) all that apply):
15"'I'am a resident of the City of Miami Peach for six months or longer. t
Home Address: L4 S1 id (�i� 1%11C _ /-A-VC l "} 1Oj)l t f'(�Cyo 2J,%
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:
El 1 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
"Ownership Interest" means the ownership of ten percent (90%) or more (including the
ownership of 90% 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 t at the facts
stated in it are true.
Gist t ?,� _d— 1�
Signatu a Date -
[�aaezfn P14
Printed Name