Rafael VelasquezMIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
RECEIVED
JAN 2 8 2022
Email: BC@miamibeachfl.gov
Telephone: 305 673.7411 CITY OF MIAMI BEACH
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 (4), as (check
(/) all that apply):
x I am a resident of the City of Miami Beach for six months or longer.
Home Address 800 West Ave #603, Miami Beach, FL 33139
o 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 ------------------------
o 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).
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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 it
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Signature Date
Rafael A. Velasquez
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence o~ine notarization,
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Produced ID
(City of Miami Beach Board/Committee Member).
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Form of Identification
lly Known
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