Gail HarrisMIAMI BEACH
RECEIVED
City of Miami Beach DEC 06 2021
1700 Convention Center Drive
Miami Beach, Florida 33139
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICE OF °'P C ITY CLERK
Email: BCOmiamibeachfi.gov
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),
7as (c ck (J) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address
.l jr0/',ami Zzll k"'.' 13011.,116.. ;j3i3C
❑ 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:
l d PA
Business Address: '?� M (fes 6c4� � l •cG. 41 33/
❑ 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 (1096) 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.
Signature
Printed Name
):.zI of Ial
Date