Jean Marie EchemendiaM IA M I BEACH
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
RECEIVE D
FEB 11 2022
CITY O F MI AM I BEA CH
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 A ddre ss 5396 N Bay Rd, Miami Beach, FL33140
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).
Name of Business _
Business Address ------------------------
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).
Name of Business Poelas "llimar
osiess Addre ss 111Lincoln Road. Miami Beach 33139
"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
are true.
02/11/22
Signature
Jean Marie Echemendia
Date
Printed Name
Sworn to (or affirmed -- ell .»sh
NOTARY
and subscribed before me, by means of~ysical presence or□online notarization,
• .s 2 Jeu nr Lleli
(City of Miam~eac~ Board/Commitze ~mber).
[_ LhUo /eo
Form of Identification
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