Jose ObandoMI A MI E H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@ miamibeachfl.gov
Telephone: 305.673.7 411
RECEIVED
FEB 10 2023
CITY OF MIAMI BEACH
OFF" r TAF 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.
l{9re J]Fe}
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 o sm e ss Ch, g Mia: b.1
Business Address \(0 Q Coe}o Le
"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.
of perjury, I declare that I have read the foregoing document and that the facts stated in it
210.73
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
eHhuay or #ovor-up, 223 ».00-& 0loo n LO
_________ (City of Miami Beach Board/Committee Member).
FL o v L€nu Produced ID
Signature of
Name of Notary, Typed, Printed, or Stamped