Derrick AttardMIAMI BEAC H
City of Miami Beach
1700 Conven1ion Cen1er Drive
Miami Beac h, Florido 33 139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl .gov
Telephone: 305.673.7 41 l
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check(../) all that apply):
0/i am a resident of the City of Miami Beach for six months or longer.
Home Address : S82,S C o lb n~ <; /l/4 . ti PH&
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 : Uo r fh,/2ec,,c,1 f?k si C..Ct I flu ~a-tJ V
Business Address: 30 q 7/5 1 .Slr:e._1 /4iu.,; 6ea76 // 1]/l/1
am a full-time employee of a business (for a minimum of six months) a~d 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 : ____ ----l.i.LS'.!:10?/:I-R=:.,.__..J,Q " D"---...!,o""J"-'~<L.:.:::,_ __________ _
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 i~ ar~ru~
/7) /4Cu~ 12--/~/ /g o:z t 4,frfafu%~: Date T I
~elZ(<,l (j( J, drt 1rJ
ted Name
Received December 21, 2021
Office of the City Clerk