Adam KravitzCity of Miami Beach
1700 Convention Center Drive
Miami Beach. Florida 33139
OFFICE OF THE CITY CLERK
Email: BCCalimiamibeachfl.gov
Telephone: 305.673.741 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
J) all that apply):
V,_ I am a resident of the City of Miami Beach for six months or longer.
nn
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).
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 (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 perj tN, I decl that I have read the foregoing document and that the facts stated in it
are true. ---
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means ofh sical presence or online notarization,
thil< day of -'-V4 b /'I JJ l —/ Z
City of Miami B ach Board/Committe Member).
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Produced ID / L /L
Form of Identification
on ly own
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Name of Notary, Typed, Printed, or Stamped
y CHARLES J.
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Received December 17, 2021
Office of the City Clerk