George NearyMIAMI B EAC H
City of Miami Beach
17 0 0 C o nventio n C enter Drive
M iam i Bea ch, Flo rid a 33 13 9
OFFICE OF THE CITY CLERK
E m a il: BC @ m ia m ibeachfl.gov
Telephone: 30 5.6 7 3.7 4 11
RECEIVED
JAN 2 8 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST A T E O F FLO R ID A
C O U N T Y O F M IA M I-D A D E
I am in com p lia nce w ith the affi liation requirem ent of M iam i Beach C ity C ode Sections 2-22 (4), as (check
( ✓) all that app ly):
o I am a resid ent of the C ity of M iam i Beach fo r six m onths or longer.
H o m e A dd ress _
o I have an ow ne rship interest (fo r a m inim um of six m onths) in a business established in the C ity of
M ia m i Be ach (fo r a m inim um of six m onths).
N am e of Busine ss _
Business A dd ress _
I am a full-tim e em ployee of a business (fo r a m inim um of six m onths) and I am based in an office or
othe r locatio n of the business that is physically located in M iam i Beach (fo r a m inim um of six m onths). 5;ge=- pos
Busine ss A ddress._3t q /y 4
"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.
m ent and that the fa cts stated in it
Printed N a
NO T A R Y
Sw orn to (o r affi rm e d ) and subscribed befo re m e, by m eans of~sical presence or o online notarization,
22a.et2 coke Naef
_________ (C ity of M iam i Beach Board/C om m ittee M em ber).
X Pr o duce s f Dues le
S ign
Form of Identification
(NO TARY SEAL)