Michael DuchonDocuSign Envelope ID: 7CDEFD74-4463-485E-A965-7B65A497901EA
City of Micuri each
E?0O Convention Center Orive
Miaoi Bech. Florida 3312
Received March 10, 2022
Office of the City Clerk
OFFICE OF THE CITY CLERK
Em ail:
Telephone:
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):
d lam a resident of the City of Miami Beach for six months or longer.
Hone A«aress Bou, Laa, [ha, ß ea l., }L, 3E'
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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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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PIS,[[,, [(][gs,5
"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 penaltyg,$gf.Pg?jury, I declare that I have read the foregoing document and that the facts stated in it
are tu° Mad. l)da. 2/28/2022
-------------- Signature o ces1cro vo62497. Date
Mic k Du c h o n
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
28th, February ,2o_, Mick D uch on
s_davor ' ..n
(City of Miami Beach Board/Committee Member).
FL. Driver's License X Produced ID
Form of Identification
Personally Known
Ca.a 'geti
,,, .,.- GOSTIN íl Wig., CHARLES J. DA
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· 1 /~~·1:;,,:\ MY COMMISSION# HH 165705 .
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(NOTARY SEAL)
signature qf Nopa£/9, Charles J. D' gostun
Name of Notary, Typed, Printed, or Stamped