Brian KeaneM I A, AIA IBEA�"*'H
i . ,I .. v W -i -" 1-11.1
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email; BC,O)miamibeachfl.gov
Telephone: 305.673.7411
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), as (check
(✓) SII that apply):
eT/ I am a resident of the City of Miami Beach for six months or longer. /
Home Address 14a? 7 Ala--* fi��, iklt, / t' t3eq,r;,4 /�_ 3 3 13f
❑ 1 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
❑ 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 (109,66) 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.
11312043
Signa re Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of�physical presence or r3 online notarization,
this day of e 20 by'D�5 �C//�'�
(City of Miami Beach Board/Committee Member),
Produced ID
Form of Identification LUIS GONZALEZ
_ Personally Kn r * MY COMMISSION # GG 964402
EXPIRES: June 29, 2024
•o:
�?rF.. ••oP' otary Public Underw ters
Signature of` l Pub
Name of Notary, Typed, Printed,' or Stamped