Imani Warren1\lAMI
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):
os I am a resident of the City of Miami Beach for six months or longer.
Home Address 1840 James Ave #3. Miami Beach FL
□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 N/ A -------------------------
Business Address ------------------------- N/A
□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 JWaªd the foregoing document and that the facts stated in it
are true. .9h) %4 · "e «o·s hu Jan. 10, 2022
Signature Date
Imani L.Warren (Emonie)
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or□online notarization,
this 1 0t11cJay of January , 20~by __ i_m_a_n_i_E_m_o_n_i_e_w_a_rr_e_n _
(City of Miami Beach Board/Committee Memb@)yemsmmmnm mm.oeme;g
Georgia Driver's License ¿ié, CHARLES J. DAGOSTIN
$? h$" "? w co so H 1sros
éph9is ExPREs: pecomber 14, 2025
$jéê Bonded Tu Notary Public Underwritors
X Produced ID
Form of Identification
Personally Known
Ciao 'get (NOTARY SEAL)
Signature of Notary Public
Charles J. D'Agostin
Name of Notary, Typed, Printed, or Stamped