Diane KleinCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF iHE. CITY CLERK
Email: BC@miamibeachfI.gov
I elephone: 305.613.7411
RECEIVED
DEC 15 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):
d
1 am a resident of the City of Miami Beach for six months or longer.
Home Address: % �o )C}�� fl- .S` p' c— I.l� iG��� l3ry,l ! / Y3 A/
❑ 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:
B�siness Address:
l� 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: 1410 lq
p,
"(/c_ -S; f
Business Address: 3U
"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 true.
`11 2, 20 Z
Signature Date
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Printed Name