Barbara KaufmanMI AMIBE
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
RECEIVED
FEB 10 2023
CITY Or M
oiiice6,",%y An
ITY CLERR
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.
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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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□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 ------------------------
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"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 e es of perju~, I declare that I have read the foregoing document and that the facts stated in it
are, a 7 2 4-: L-L.. .. , -·· ....-···, ,,_
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Printed Name
NOTARY
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Sworn to (or affirmed) and subscribed before me, by means off physical presenc~,or a online notarization, 95" 1j , .a. p? · 'y 9?
this (_day ot Lora/ ,20l2y ['gpkg (aaf pg,
(Gity of Miami Beach Board/Committee Member).