David GrieserMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC anmiamibeachfl.gov
Telephone: 305.673.741 1
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) J,that apply):
I am a resident of the City of Miami Beach for six months or longer.
r
Home Address
p 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.
Underp,pnafties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are tr...
Signature Date
David Grieser
Printed Name
NOTARY f
Sworn to (or affirmed) and subscribed before me, by means oph,sical presence or o online notarization,
thisL day of20_by�✓t�
(City of Mianai Beach Board/Committee Member).
Produced ID f� //J��2��5 X) f
Form of Identification
Pe�r�ga lly ow
Signatu a otar lic
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGO87IN
kMY COMMISSION # HH 165705
*,V EXPIRES: December 14, 2025
,rFOF'` Bonded Ttuu Notary Pubic Underwriters
(NOTARY SEAL)