David GrieserM IA N\I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 741 l
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):
IX I am a resident of the City of Miami Beach for six months or longer.
Home Address 1754 Meridian Avenue, #201 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 vue pou go 12/27/2021
Signature 1/- Date
David Grieser
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, b means of o physical presence or o online notarization,
th is 9Î day of D f'.~~~20 .)_f by -~-+-1-~t=-------+,,_,__-'----'""'----==---,-__;:::;=-------
Produced ID
(Cit¥.-.of Mia2) Beach Board/Committee Member).
Ft_ vet Leo_Se
Form of Identification
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped