Lauren CohenMI/AM/BEACH
City of Miami Beach
1700 Convention Center Drive
Mi am i Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeach1.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
RECEIVED
MAR 120723
CIT Y O F M IAMI BEACH
OFFICE OF THE CITY CLERK
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in com pliance with the affiliation requirement of Miami Beach City Code Section s 2-22 (4), as (check
·) a} that apply):
1 am a resident of th e City of Mi am i Beach for six mon ths or longer.
ore ares. 380 (a ke9euo De, Har, Real L 33/+0 ,
[I I have an own ership interest (for a minim um of six months) in a business establish ed in the City of
M iam i Beach (for a minim um of six months).
Nam e of Business _
Business Address __,_ _
□I am a full-tim e employee of a business (for a m inimum of six months) and I am based in an office or
other location of th e business that is phy sically located in Miami Beach (for a minimum of six month s).
Nam e of Business ---------------------
Business Address ---------------------
"Ownership lnteresf' 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 pena ties of perjury, I declare that I have read the foregoing document and that the facts stated in it
«eve»- >/\l2%
Signature Date
Laavn (Clea
Printed Nam e
NO TARY
Sworn to (or affirm ed) and subscribed before m e, by mean s of a physical presence or o online notarization,
e Ea fwd .a@ . )a. A_ @lug
by
,(City of Miami Beach Board/Com mittee Member). 7 .a.so f6 @ v/ oz
Form of Identification
Pers onally now n
Si
Gii. ALEN BETANCOURT ;~m\ bi -_i~eofflonda $$ 23;2; +our P%/Kji8SE 3 {~; commissibl> @i ?d% comm. tires My 1,