Prakash KumarMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCRmiamibeachfl.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) all that apply):
❑ I am a resident of the City of Miami Beach for six months or longer.
Home Address '5325 C '4JLeyUU VAY1 11,- C4 64_1mIV\_ FY- X31 s�
❑ 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 Busin
Business
❑ 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 in it
are trup..1 ~._..-.._..._
!' �10 (
Signature .i - Date
Prakash Kumar
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence or ❑ online notarization,
this day of ' /�� , 20 ,y
(City of Miami Beach Board/Committee Member).
Produced ID �%�� l/�/��S
Form of Identification
Per Wally w
!�
Signat e ary P
Name of Notary, Typed, Printed, or Stamped
�Y? CHARLES J.OAGOSTIN
MY COMMISSION # HH 165105
o EXPIRES; Recember 14, 2025
Bonded Thru Notary Public Underwriters
(NOTARY SEAL)