Michel Tessiert\A I A/M I B EAC H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: B�miamibeachfl.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
(✓) all that apply):
I am a resident of the City of Miami Beach for six months or
longer. ('�
Home Address y \ f c s—
❑ 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 Busin
Business
p 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
Business Address
"Ownership Interest" means the ownership of ten percent (109,6) 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 per' I declare that I have read the foregoing document and that the facts stated in it
are true.
Signature Date
"\cc—
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence or ❑ online notarization,
this 70 day of JC&yVJ& "Y , 202Z by M i cJ—& TOSS 4-, -
(City of Miami Beach Board/Committee Member).
Produced ID PA, b YlV" I f lel Uk'lJPi
Forra,of I9ehtification
Personally
Signature of Nota6 Public
Name of Notarv. Tvoed. Printed. or Stamoed
.•; wy PIIBi.
;p
MY COMMISSION
EXPIRES 1.3.2027
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