Tanya BhattMIAM I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ail: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
FEB 2 8 2023
CITY OF MIAMI BEACH
OFFICE OF T HE 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):
s;i I am a resident of the City of Miami Beach for six months or longer.
ER }3it/ p 2->) 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 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.
Under penalties of perjury, I clare that I have read the foregoing document and that the facts stated in it
are true. , 1y3/2
rHH 2L i2S
Date Signature 22g Arr R +t ea Na#
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online notarization,
20 » Yr t,.a023 »». Tn _ Inoa#
--------- (City of Miami Beach Board/Committee Member).
a s o fl 0n v Lunr+
Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped