Raquel PachecoMIAMIEF�CN
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: X30 miamibachfi.Qov
Telephone: 30 S. 67 3.7411
RECEIVED
DEC 06 2021
CITY OF MIAMI BEACH
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),
as, (check (J) all that apply):
E I am a resident of the City of Miami Beach for six months or longer.
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Home Address: U -6-L
211,1 -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:
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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 (109/6) 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
stated in it are true.
Signatufer-
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Printed Name
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Date