Elizabeth WheatonCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC cDmiamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
JAN 2 6 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
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. / ``�� V
Home Address 2=D 11 G (�V/ _ J 10 1QL # 6 f
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 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 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 penalties perjury, I declare that I have read the foregoing document and that the facts stated in it
are true.
2� 202.3
Signatu a Date
Elizabeth Wheaton
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me,, by means o hysical presence or ❑ online notarization,
tb day oKT4/1O , 20') - by
KProduced ID
_ (City of Miami Beach Board/Committee Member)
Form of of Identification
Per ally own
Signatue o o y Publi
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGOSTIN
MY COMMISSION # HH 165705
EXPIRES: December 14, 2025
Rn WHY Public Underwiiters
(NOTARY SEAL)