Debra SchwartzCity of Miami Besch
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email:
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST ATE 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):
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Home Address
I am a resident of the City of Miami Beach for six months or longer.
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□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).
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"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
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Signature
D eb r a H±. Shoat
Date 1 '
Printed Name
N O T A R Y
Sworn to (or affirmed) and subscribed before me,,by means of physical presence or g online notarization,
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________ (City of Mi mi Beach Board/Committee Member).
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Form of Identification
Produced ID
Name of Notary, Typed, Printed, or Stamped
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¿pg.is; EXPIRES: December 14, 2025
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