Owen Basner Sep 2022M IA M IB
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CL ERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
AUG 1 7 2022
CITY OF MIAMI BEACH
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 Address 5931 North Bay Road, Miami Beach, FL 33140 _
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 _
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).
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
"0uw /V 8/17/22
Signature Date
Owen Basner
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o~ysical presence or o online notarization,
st7.aero Nast ,zo 22o. OeRu [A5y@
X Produced ID
(City of Miami,each Board/Committee Member). Ft _fee> A en s
Form of Identification
Per5on ally Known
Signatur
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(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped