Lynette Long1\A I AM, I B EAC F1
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(d),miamibeachfI.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):
m I am a resident of the City of Miami Beach for six months or longer.
Home Address650 West Avenue, Apt 501, Miami Beach, FL 33139
p 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
❑ 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 Add
"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,
entity or business association,
Lynette Long
Printed Name
NOTARY
corporation, limited liability company, or other
agoing document and that the facts stated in it
January 22, 2023
Date
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence or ❑ online notarization,
thisZ day oOC 20 by A 1
Yl Wil
(City of Miami Beach Board/Committee Member).
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Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped 'a//s, .OFF
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