Galen TreuerMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCOc miamibeachfl.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):
U3 1 am a resident of the City of Miami Beach for six months or longer.
Home Address1150 Euclid Ave #301 Miami Beach, FL
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 Business
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 penal ' s of perjury, I declare t ead the foregoing document and that the facts stated in it
are true ol,--_ 1 /6/23
Signature Date
Galen Treuer
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
thf� day o20,1?3by
(City of Miami Beach Board/Committee ember).
Produced ID J' n
Form of Identification
Pe o ally K n
CHI
Si nat re Notar
9 y MY COMMISSION # HFi 165705
a• EXPIRES: Dominber t 4, 2025
Name of Notary, Typed, Printed, or Stamped "yfoFF °Q° Bonded Th. Notary Public ur,4ermiters