Charles Madison Sep 2022MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(o)miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVE®
OCT 25 2022
CITY OF MIAMI BEACH
OFFICF _'4r: r`ITY CLERK
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):
❑XI am a resident of the City of Miami Beach for six months or longer.
Home Address: 1020 Meridian Ave Apt 711, Miami Beach, FL 33139
❑ 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.
/s/ Charles A. Madison
Signature
Charles A. Madison
Printed Name
10/19/2022
Date