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Johann Moore Sep 2022City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email: BC@miamibeachfl.gov Telephone: 305.673.7411 AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH 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:_________________________________________________________ □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:_________________________________________________________ Business Address:_________________________________________________________ “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. Signature Date Printed Name 717 Jefferson Avenue, Apt 8, Miami Beach, FL 33139 Johann Moore Johann Moore 22 July 2022 X Received July 22, 2022 Office of the City Clerk