Johann MooreCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC tai
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
(V) all that apply):
cX I am a resident of the City of Miami Beach for six months or longer.
Home Address 717 Jefferson Avenue, Apt 8, Miami Beach, FL 33139
[3 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
[3 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 true. Jan 10 2023
Signature Date
Johann Moore
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or u online notarization,
this // day of jolntlotr� w, 209) by [0110,11411 14002C
(City of Miami Beach Board/Committee Member).
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