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William Roedyb r $ ��1 Citta of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email: BC@miamibeachf1.rtov Telephone: 305.673.7411 AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH STATE OF FLORIDA COUNTY OF MIAMI-DADE 4 I am in compliance with the affiliation requirement of Miami Beach City -Godo t,eccions 2-22 (d), as ((Jv� (c+c � (✓} all that apply): tey* l am a resident of the City of Miami Beach for six months or (,)ngor,; Home Address 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 TQnfhs). Name of Business I'll Business Address=.__.__ .__.__._._ . / r3 I�am a full-time employee of a business (fo minimum of six months) and I gni based in an office or other location of the business that is physteally located in Miarni Beach (fora minimum of six rrionths). ,, Name of Business_ �� __.__. _ _ f usiness Address___ ---------- "Ownership _.._ _"Ownership Interest" means the ownership of ten percent (10%) or more (including the ownership of ,i ©,% or more of the outstanding capital stock) in a Business. 'business" means any sole propriezolShip, sponsorship, corporation, lirnited liability company, or ofher' en(i4/ or business association, i. r Under pc naltic.s of perjury, I declare that I have read the foregoing, docurrient �@i id that the facts stated in i> �r I are twe. ,J. .. ..._. �� _ .. Signature s Da to Printed Name NOTARY Sworn to (or affirmed) and subscribed before rne, by means of r3 [ hysicai,presence or n online notarization, �� dsV4•"'i. of v6 �� P thin, C5 day 20 by _.. f y;9iiB1@.@5(��d ...... (City of Kfiiami Beach BoardlCQnintittee Member). sp I� {educed IC) _. __ _. _ C,C`taUMER� Form ofldentificatiort` GE 972087 Per-snnaI y nown F EftCS W 24 2M4 lz- /�'X'{ ; _ (NOTARY SEAL) � Sidnatuie of iN')J- ry PubRU lic ` 16, t svg, GE.,e",ry