Francinelee HandMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(@miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVE
DEC 0 8 2021
CITY OF MIAMI BEACH
pFFI ,F 4:�,r THF 01TY 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),
;(ch (J) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address:
❑ 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). 40
Name of Business:
Business Add
❑ 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). Y! 0
Name of B
Business Address:
"Ownership Interest" means the ownership of ten percent (10%) 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 tru .
Signatu
—TV -ee42��q aG
Printed Name
�ec
Date
/4�c