Diane Connolly GrahamM IA M I B EAC H
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
FEB 3 2022
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):
□I am a resident of the City of Miami Beach for six months or longer.
Home Address _
□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 Address _ y 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 locate in Miami Beach (for a minimum of six months).
Name of Business [ vl 1Id l l' ' \fl2Lr'
usness Aaaress Ly É. >, Lio (cl/
"Ownership Interest" means the ownership bf en 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.p that I have read the foregoing document an t the facts stated in it
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Printed Name
NOTARY
Sworn to (or affrmped) and subscribed before me~ ".'eans ~cal presence or o online notarization, ra/1or, Dive oNuall9 bak A
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/$~· .. ····.>• MY COMMISSION# HH 165705 i; :i EyPIRES: Decam bor 14, 2025 <%, S: ' ,nAanriterg %2.3? ponded Thru Notary Public Undef "9£.f°'
Form of Identification
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