Michael Band Sep 2022A' Air I [
RECEIVED
City of Miami Beach y
1700 Convention Cn^ntcn Drive OCT 112022
Miaini Bcwic h, Florida 33139
OFFICE OF THE CITY CLERK CITY OF MIAMI BEACH
Email: P miamibearl�(I. v OFFICE OF'rHF CITY CLERK
Telephone: 805,673 ,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), a (check
(V) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address im 9ercA.r—L
rI I have an ownership interest (for a rninimum of six months) in a business established in the City of
Miami Beach (for a minimum of six months).
Name of Business
Business Address
0 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 (10%) or more (including the ownership of
10% or more of the outstanding capital stock) in a business,
xonsorship, corporation, lirnited liability company, or other
-,ad the foregoing docurnent and that the facts stated in it
i - ,.7,
Gate
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of /Physical presence or c: online notarization,
this day of ?� , 20 , by ,�
_ g ,. -y
........ ._w. (City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Personally Known
SUSAN_ -
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Signature of Notary Public �.� ms s. 7p
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Name of Notary, Typed, Printed, or Stamped