Marcia Duprat LeporiM IA M I B E A C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
RECE IVE D
FEB 10 2023
C ITY O F M IA M I 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):
e am a resident of the City of Miami Beach for six months or longer.
Home Address fa 'et_duo Qg l toy
□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 penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
ares (ou a b oa101\03
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online notarization,
ms 1_«yo_he zo) /aca ). epois
_________ (City of Miami Beach Board/Committee Member).
f Dae (c Produced ID
Form of Identification
Personally Known
s;gn~c(1
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped PATRICK D. CAMM
MY COMMISSION # HH 254869
EXPIRES: Apr1l 19, 2028