Daniel DiazM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl goy
Telephone: 305.673.7411
RECEIVED
MAR -8 20272
CITY OF MIAMI 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):
o I am a resident of the City of Miami Beach for six months or longer.
Horne Address _
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 _
V I am a full-lime employee of a business (for a minimum of six months) and I am based in an office or
f\ other location of the business that is physically located in Miami Beach (for a minimum of six months).
var-or sure». Eloi bec dlbo
er. 1Zò rtev dioa M.
"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.
of perjury, I declare that I have read the foregoing document and that the facts stated in it
I I' E0by77
Signature Date
DAn4 Dz
Printed Name
(City of Miami Beach Board/Committee Member).
2 eoceao f bres /io5e
Form of Identification
Signatu
Name of Notary, Typed, Printed, or Stamped
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