David NguahMI AMI BEA H
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7 411
RECEIVED
FEB 2 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
( ✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address L20> Ad' SHH Hr, ie,Ai ',3213$
□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 or Business. _buge.s GLLtm c.
Business Address Ii or> oct 8Ql_,y e._ _6e0 4 h 3(3$
"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:z ~e proprietorship, sponsorship, corporation, limited liability company, or other
entity or business association.
r pbnalties of perjury,, declare that l have read the foregoing document and that the facts stated in it
alls
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of a physical presence or a online notarization,
us 42-aay toruon _., 2o.3 y Doi_d Noyvc-/
0
________ (City of Miami Beach Board/Committee Member).
Pt bond' Ano-4€C Produced ID
Form of Identification
Signatur
Name of Notary, Typed, Printed, or Stamped