Brian EliasCity of Miqmi Besch
I200 Convention Center Drive
Miomi Beoch, Florida 33139
OFFICE OF THE CITY CLERK
Ema i I : FC.@m iamiF_qaqhtl.q.pv
Telephone: 305.673.7 41 1
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 Ad lo ,(1.39131
D 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 Add
lam a full{ime 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 Add
"Ownership lnterest" means the ownership of ten percent (10%) or more (including the ownership of
10% or more of the outstanding capital stock) in a business.
"Buslness" means any sole proprietorship, sponsorshrp, corporation, limited liability company, or other
entity or buslness associaflon.
Under pe of I have read the foregoing document and that the facts stated in it
are
Printed Name
Sworn to (or affirmed) and subscribed before
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I presence or n online notarization,
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me, by means of {physica
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NOTARY
tnis 2/ day of zoA)by
-V- Personally Known
nature
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(City of Miami Beach Board/Committee Member)
Form of ldentification
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Produced lD
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Name ;iI6tan/,Tiped,'pnntFd, or Sta mped
Received January 24, 2022Office of the City Clerk