Gustavo BriandM IAM 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 .7 411
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 Aaares _9hl La)o pué A _0 Ml 4FL33134
'(f 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 ot Business éßSny o ß2up Sn/1O
Business Address I7O1 _UNSg [2_ o ¿ß- DR. n [C MA3y 1 33136
'if 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 M iam i Beach (for a minimum of six months).
Name ot Business ( v Sn 9 2u A y 6rV ]O
Business Address _$4 _AS y2
"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 p JU , declare that I have read the foregoing document and that the facts stated in it
are true. ]-4-2027
Signature Date
Printed Name
N O T A R Y
Sworn to (or affirmed) and subscribed before me, py means of u physical presence or online notarization,
o,_00U88,22M.6u S/U 3 4
(Cit of Miami eac~ Board/Comze Member). ,..~ ... !.! .... ~ .. !!!!!!!!!!!!!!!~~!!!!!!!~!!!!!!!!!!!!!!~ X eco - J u> -co i4 #%fe .fzizz.
orm of Identification [Éj,„gdiÉ ExPREs: Docomtor 14, 2025
OW, > í#;jji&' Bonded Thru Notary Public Underwriters
(NOTARY SEAL)
N a m e o f N t a r; T u n e r{ printer or S tamn e rd