Francsco Diez-Rivas1-1-1
AA I AM 1 B FAC"
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
DEC 15 2021
OFFICE OF THE CITY CLERK CITY Chi= MIAMI BEACH
Email: BC(@miamIbeachfl.gov 0FFI0F j )r THE CITY CLERK
Telephone: 305.673.741 1
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):
LI I am a resident of the City of Miami Beach for six months or longer.
Home Address: 57G6a 4o L ^/_'5 1y7,, ,A41'.-3c4,c C
❑ 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:
Business Address:
"Ownership Interest" means the ownership of ten percent (1091o) 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 penaltie el that I have read the foregoing document and that the facts
stated in it are tru .
1a2—o7^ ZI
Signature Date
Printed Name