Juanita A GozaMI A MI B
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@ miamibeacllfl.gov
Telephone: 305.673.7411
RECEIVED
EB 14 2073
\AMI BEACH or OE,} iv ciii
OF FI CE O '
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):
IZl I am a resident of the City of Miami Beach for six months or longer.
Home Address 1120 Pennsylvania Ave, #108, Miami Beach, FL 33139
□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.
I declare that I have read the foregoing document and that the facts stated in it
2/1/2023
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
_________ (City of Miami Beach Board/Committee Member).
Pi_nu« uo-4 Produced ID
Fo~of I ntification
Personally own
•
Signature of Not y Public
Name of Notary, Typed, Printed, or Stamped