David SuarezMIAMI BEACH
City of Miami Beach
1700'Cnv,-*n1ior Cerior D ve
M>am 3oocl•. Florido 33134
OFFICE OF TtiE CITY CLERK
Telephone: 305.673.7411
RECEIVE®
DEC 16 2021
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CIT Y OF PAIAMI BEACH
I arri .n compliance with th4; affiliation requirement of Miami Bea;;h City Code Sections 2-22 (4).
as f.che,:k (•:') all that apply):
I art) a resident of the City of Miami Beach for six months or longer.
�1
Home Address: ' -r',4�tc _ A
❑ I have an ownership interest (for a minimum of six months) in a business estahlished in the
C;ty of P,tiami Beach (far a miririum of six months)
Name t Business:
Business Address:
❑ I am a foil -time enihloyee of a business (for a mniniurri of six rlonthsl and i am basec in an
office or other location of the Lmsiness that is physicaky located .n M am Beach (for a
minimum of six months}.
Name of Business:
Business Address:
"Ownership lntorest" means the ownership of fen percent ! , 0%) or n7ore (inrtt;d)0g :he
ownership of 10% or more. of the nutstandrnq c-,ap tal stor:kj in a business.
"Business' means any sole ompnetorsh.p. spoosorship..;orporairc:n, ;emdecl hab4dy company.
or other entity or L)zjsiness asslx;iation.
Under penalties gf perils, I declare treat i have read the fo,ogoing document ano trial the facts
stated in it arelr u
/ J _ 1
Sigrla4ir� Date
Printed Name