Cori Rice Sep 2022MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(6imiamibeachil.aov
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):
❑ 1 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 ayminimum of six months).
Name of Business: p,�(1-I c IiAPUe&y�/�.T� (nlY IPS Z((1]]1��1p,� �11.I.L
Business Address: ILIO) I�,0II1AS TAX {mIOMI (Jeac)^ 33ft
❑ 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
Business
'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. � q
IA. Y/w" PQ-H-�
Signa ure Date
r—OJt �1f�
Printed Name