Sarah NelsonM IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
JAN 12 2022
C ITY O F M IA M I B E A C H
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
i:s/ I am a resident of the City of Miami Beach for six months or longer.
Home Address: 00 M.Melo Ave M3 33l(0 ------------------------------
~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).
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Business Address: 4 O u. Mc'di ve MB 32/(0
i
D 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 " are true.
) 4 0 o, 2o22
Date
Printed Name