Christopher RollinsIA M IB H RECEIVED
FEB 7 2023
City of Miami Beach
1700 Convention Center Drive
Mi am i Beach , Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
CI T Y O F MIAMI BE A CH
OF FICE OF +IE CI T Y CLER K
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST ATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
DI lam a resident of the City of Miami Beach for six months or longer.
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[] 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).
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l am a full-time employee of a business (for a minimum of six months) and l am based in an office or
other location of the business that is physically located in Miami Beach (for a minimum of six months).
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"O w nership Interest" m eans the ow nership of ten percent (10%) or more (including th e ownersh ip of
10% or more of the outs tanding capital stock) in a business.
"Business" m eans any sole prop rietorship, sp onsorship, corp oration, limited liability company, or other
e n tity o r bu sin ess a s socia tio n .
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
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Signature v Date
CH(snt ± L LU A
Printed Name
NOTARY
(City of Miami Beach Board/Committee Member).
Produced ID , ]
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Sworn to (or affirmed) and subscribed before me, by means of(physical presence or online notarization,
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Form of Identification
Name of Notary, Typed, Printed, or Stamped