Jill ShockettMIAM I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
EB 10 2023
MI AMI BEACH or' O, Tie crfcin
OFFICE "
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
(/0,all that apply):
rr/ I am a resident of the City of Miami Beach for six months or longer.
HomeAddress /..5"70~
□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 _
a 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
are tr + 094 7, 3,023
Date{
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presenc e or online notarization,
his Ike«d ay ot torr q..20 23y. hl]Co~et
________ (City of Miami Beach Board/Committee Member).
rut( hC V Produced ID
Form o
Personally Kno n
Signature of Notary
Name of Notary, Typed, Printed, or Stamped