Jill Shockett Sep 2022,MIAMI BEA(, -'f'
CTT of ;vtinini Leach
17 00 Convu-nflfon G;nl ,r Drive
Micuri °each, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCr; '.
Telephone: 305.673.74 i 1
RECEIVED
0 C T 21 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY 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 (J) all that apply):
[;( I am a resident of the City of Miami Beach for six months or longer.
-11 v
Home Address:
❑ I have an ownership interest (for a minimum of six rn inths) in a business Established in the
City of Miami Beach (for a minimum of six months).
Name of Business:
Business Address:
❑ 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.
"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 i1i it are true.
Sign L (� Date
Printed Name