Liliam LopezM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email:. B C @m iam i b each f.g ov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
S T A T E O F F LO R ID A
C O U N T Y O F M IA MI-D A DE
I a m in complia nce w ith the affi liatio n requirem e nt of M iam i Beach C ity C ode Section s 2-22 (4), as (check
(/) all that apply ).
o I am a reside nt of the C ity of M iam i B each for six m onth s or longer.
H o m e A ddr e ss 420 0 Al ton R oa d. M ia m i Be ach, FL 33140
u have an ow ne rship In terest (for a m inim u m of six m o nths) in a busine ss established in the C ity of
M iam i B each (for a m in im um of six m onths).
S o uth F lorid a Hispanic C ha m be r of C ommerce [[a m e f [[8]m@Si
B usiness A dd ress 333 A rthur G odfr ey R oad . Su ite 300., M ia m i Be ach, FL 33140
o I am a full-tim e em p loye e of a business (for a m in im um of six m o nths) and I am based in an offi ce or
othe r loca tio n of the busin e ss that is physica lly located in M ia m i Beach (for a m inimum of six m on ths ).
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[1JS/mess (]([fess
Ownership Interest" means the ownership of ton 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 busin ess associ a tion.
U n d er pen al ti e s of perjur y , I declare that I have read the foregoing documen t an d that th e fact s stat ed in it
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Li lia m M . Lo pez
P ri nte d N ame
N O TA R Y
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Bon ded thr ou gh Nation al Notary Assn,
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(N O TA R Y SE A L)
N a m e of N otary , Type d, Printe d , or S tam ped
Received December 21,2021
Office of the City Clerk