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MIAMI BEACH
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City of Miami Beach tREGEIV �` 4
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1700 Convention Center Drive �b
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK t,l'It, E, iuil;`f+l=i�Cl 1
Email: BCCa�miamibeachfLgov s Its G11 Y CLERK
Telephoner 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 (J) all that apply):
4
1 I am a resident of the City of Miami Beach for six months or longer.
Home Address: Y- l (Ave
❑ 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:
ILBusiness Address:
"Ownership Interest" means the ownership of ten percent (101%) or_nnor o (including the
ownership of 10% or more of the outstanding capital stock) in a busiooss.
'Business" means any sale proprietorship, sponsorship, corporation,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
4at
re true.
I ry Date
Printed Name