Esteban PorcelliMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Emai l: BC@miamibe achfl.gov
Telephone: 305.673.741
RECEIVED
MAR 3 2023
CITY OF MIAMI BEACH
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 Miam i Beach for six months or longer.
Hom e Address 4 _J Drsl cRel 3. P}?r0,M1AM1 B] F 3314o
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.
Signature
€$744N/
that I have read the foregoing document and that the facts stated in it
03/01/22=>
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of u physical presence or o opline notarization,
» 1 a a_zs, £rcft pev et i
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(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Personally Known
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(NOTARY SEAL)
Name filary, Typed, Printed, or Stamped