Dana Turken1 ' I B EACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email BC 1 kniamiheagt&gov_
Telephone: 305.673.7,41 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 10(t'f
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 Busin
Business Address
1 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 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 1 have read the foregoing document and that the facts stated in it
are true.\
Signature Date
Printed Name
NOTARY
Sworn to (or affir d) and subscribed before me, b means of physical presence or o online notarization,
this t1lday of 20 1 by
City of Mia m/*Beach B..00ardd/Commitee Member)
Produced ID R— X y -s `xL
Form of Identification
erso ally Known
Signature of Nofaryxlic
Name of Notary, Typed, Printed, or Stamped
RCharles J. Dg'n
NOTARY PUBLIC
STATE OF FLORIDA
w.. Comm# GG168171
Expires 12/14/2021
NOTARY SEAL)