Jeremy WachtelMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC )rniamibeachfi Bov
Telephone: 305.673.741 1
RECEIVED
DEC 2 7 2022
CITY OF MIAMI BEACH
OFFICE OF THE 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
(✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
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Home Address ir-, 00 C •( rr? "a �' `1 ' t J ) r tivy t 1 ` +� l rr»
I have an ownership interest (for a minimum of six months) in a business established in the City of
Miami Beach (for a minnimmum(of six months).
Name of Business raR _
Business Address +tui -m kac-� ,r - 3 SI N
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 Busin
Business Add
t4
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,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 pedury, I declare that I have read the foregoing document and that the facts stated in it
are true.
Sign a Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
this day of C 20 - -by
7
Produced ID
(City of Miami Beach Board/Committee Member).
Form of Identification
Personally Known
Sign ture of to uplic
Name of Notary, Typed, Printed, or Stamped _
UNDASCHECHTER
MY COMMISSION A HH 066733
EXPIRES:Jarwaq 30,2025
Bw,dW Ttn Noir, P'v* Undm0tors
(NOTARY SEAL)