Henry WilliamsMIAMI BE,�,C�
City of Miami Beach
1700 Convention Center Drive
Miami Bcach, Florida 33139
OFFICE OF THE CITY CLERK
Email L; ,_
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 Q0, �tn i.'
V3�
❑ 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 Busi
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 a .
Business Address —\ 0 S`� UC fc,v�
"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.
Un de nalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are
Sig ature Date
i
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
this V1 day of ICAY) 2013 by -H-lin lei
(City of Miami Beach Board/Committee Member). a�`�`"' KEIIA4j'"1%,
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Produced ID A" V Q/'I S
Form of Identification
Personal) K w RES
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Signature of Notary Public'(}+,..0FFLOR� ',c
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Name of Notary, Typed, Printed, or Stamped "#0111111141111%