James RodgersCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@_miamibeachfl.4ov
Telephone: 3 05.673.7411
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
(J) all that apply):
p 1 am a resident of the City of Miami Beach for six months or longer.
Home Address 947 Lenox Ave, Apt 504, Miami Beach FL 33139
❑ 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
❑ 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 (905,o) or more (including the ownership of
90% 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 penM�=-
have read the foregoing document and that the facts stated in it
are true. JanuaryX2023
Signature Date /
James Odgers
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means ofphysical presence or ❑ online notarization,
this 13 day of iiikW—W4 , 20 - D by J 1v� �7 •��� lis i
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Personally Known
Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped
9T6WALL
��
:oY ►G°G . TALITA CHIARELLI
y Netary Public •State of Florida
Commission r GG 967309
My Comm. Expires Mar 9, 2024
5onded through National Notary Assn.