Christopher Williams Sep 2022M I AM I Ei) li - (11
RECEIVED
City of Miami Beach SEP 22 2022
1700 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email: 13C(@mIamIbeachfI.gov
Telephone: 305.673-7411
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
(J) all that apply):
r� I am a resident of the City of Miami Beach for six months or longer.
Home Address 1!0 f'> D � � `� � � �� �} &! %!M, �Y /,l Il 1 C. i i �l I
❑ 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
n 1 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 (1091o) 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 documentandthat the facts stated in it
are true..,
(
Signature Date
W"A/I•1n
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of Vphysical presence or n online notarization,
this. I day of _� drt.— 201(- by
(City of Miami Beach Board/Committee Member).
Prodttced ID
.''' Form of Ide
�Z, Personally Known
It
Signature of Notary Publi
Name of Notary, Typed, Printed, or
dh
1ia�Pu • WILLIAM J REYNCILOS III
XNotary Public • State of Florida
'OTARN(rrfflfiAlk�H 135303thruh Natlonal Notary Assn.
rv:My Comm. Expires May 27, 2025
��'� Bonded