Tiffany HecklerM IA M I B EAC H
City of Mi am i Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@mìamibeachfl.gov
Telephone: 305 .673 .7 41 l
RECEIVED
JAN 18 2022
CITY OF MIAMI BEA H
OFFICE OF THE CITY CLERK
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 (), as (check
(6) a)hat appl y):
✓I am a resident of the City of Miami Beach for six months or longer.
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o I have an ownership interest (for a minimum of six months) in a business established i the City of
Miami Beach (for a minimum of six months).
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Business Address ----------------------
o,/ I am a full-time employee of a business (for a minimum of six months) and I am based i 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 wnership of
10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability comp ny, or other
entity or business association.
Under pen "
are true.
ave read the foregoing document and that the fac s stated in it
\
Date
N O TA RY
Sworn to (or affirmed) and subscribed before me, by means of jyhysical presence or a online]notarization,
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~ of Miallj'\Beach Board/C?mmit~e Me ber).
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Form of Identification
son y Known
Sign
Name of Notary, Typed, Printed, or Stamped
:.3... CHARLES). IN {$rs e:
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