Gail HarrisMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33134
OFFICE OF THE CITY CLERK
Email: l3C(a)miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
DEC 27 2022
CITY OF MIAMI BEACH
OFFICI CiP + HE 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
(J) all that apply):
I am a resident of the City of Miami Beach for six months or longer. a
Home Address �✓��_� Z — r
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
416)
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 o erjury, I declare that I have read the foregoing document and that the facts stated in it
are true.
Signatur Date
Ris
Printed Name
NOTARY
Sworn to (or affirmed) and subscribedbefore me, by means of o physical presence or o online notarization,
this�r/ ft�y of 20P9 by
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
-11 so Ily Known
Sign4trreOf Ng&ftublic
Name of Notary, Typed, Printed, or Stamped
`�.;��pY P(jg,•., , CHARLES J. DAGOSTIN
�L MY COMMISSION II HH 165705
�A. a EXPIRES: December 14, 2025
Bonded Thru Notary Public Underwriters
(NOTARY SEAL)