Patricia Henao-van BeekCity of Miami Beach
!7 0) Conv entio n Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: C@lm.ambeach1l.gay
Teleph on e: 30 5.6 73.7 4 11
RECE IVE D
MAR 2 2023
C ITY OF MI AM I BE A CH
OFFICE OF THE 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):
lam a resident of the City of Miami Beach for six months or longer.
Home A«are s_]IL 5 Eay Drive Ma mi £each FL 3314]
□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).
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DI lam 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).
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"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 bus ess association.
rjury, I declare that I have read the foregoing document and that the facts stated in it
March1 2023
Signature
Palrcer Hlenao- an 3eek
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of u physical presence or online notarization,
oe2day or.wh a0 o, [m i 1 e noo -y _lee
9
(City of Miami Beach Board/Committee Member).
{ Or r L une Produced ID
Forrl-f I ntification
n
e-
Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped