Steven AdkinsCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC )rniamibeach1gov
Telephone: 305.673.7411
RECEIVED
JAN 30 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
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
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
p 1 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 Miami -Dade Gay & Lesbian Chamber of Commerce
Business Address 1130 Washington Ave - 1st FL N Miami Beach, FL 331
"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 j�dehat I have read the foregoing document and that the facts stated in it
are tr 1/10/2023
Signature Date
Steven Adkns
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o�ysical presence or ❑ online notarization,
this / 0 day of�' 20 by �� a!,I V-,'- _�
Produced ID
(City of Miami Beach Board/CQmmittee Mem
a /) _S
Form of Identification
_ Per Wally nown
Signaty e N ry Potrc
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGOSTIN
* MY COMMISSION 8 HH 185705
EXPIRES: December 14, 2025
Bonded Thru Notary Public Undwmbra
(NOTARY SEAL)