Johann MooreM IA M I BEACH
City of Miami Beach
1 700 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):
~ I am a resident of the City of Miami Beach for six months or longer.
Home Address 7y7 Jefferson Avenue, Apt 8, Miami Beach, FL 33139
o 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 _
o 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 perjury, I declare that I have read the foregoing document and that the facts stated in it
are true. Jolav M oore 16 D& 2O21
Signature Date
Johann Moore
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or online notarization,
_________ (City of Miami Beach Board/Committee Member).
this 16thuay or December ,2o1_y Johann Moore Eccccccccccccece-eeeee=e
Wig., CHARLES J. DAGOSTN
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X Produced ID
Form of Identification
Personally Known
Ciao, D'A, out,
Signature of Notary Pub~
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped
Received December 16, 2021
Office of the City Clerk