Jane HayesMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: 13C(a)miamibeachf1.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 1 )00 � �/� a\ fie— I "�— V r I
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 Busin
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 Busin
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 nalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are ru .
a
Sig6atuk Date
Janie Hayes
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
this 13 day of IG-nV(A 2013 by
)C Produced ID
(City of Miami Beach Board/Committee Member).
l0ny4,-r- (S U.,c2I\ P
Form of Identification
Pers nalln
Sig ure of�ar Public
Name of Notary, Typed, Printed, or Stamped
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