David DoeblerMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
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):
1' I am a resident of the City of Miami Beach for six months or longer.
Home Address 800 West Ave, Apt 212, Miami Beach, FL 33139
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 enalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
5/true
12/14/2021
Date
David Doebler
Printed Name
NOTARY
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X Produced ID 7E ". 6i identification
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Name of Notary, Typed, Printed, or Stamped
ARY SEAL /~
A~-:~~\ CHARLES J. DAGOSTIN ~
i;; ¿? MY COMMISSION # HH 165705
5 2 EXPIRES: December 14, 2025 •,·i6°· p ata '+ "f,'°" odedThru Notary Public Underwriens
Received December 17, 2021
Office of the City Clerk