Nikolai O'ConnorM IA M IB E H
City of Miami Beach
1 700 Convention Center Drive
Miam i Beach, Flor ida 33139
O FFIC E O F TH E C ITY C LERK
Em ail: BC @m iami be ach fl .gov
Telephone: 305.673.7411
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):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 1025 Alton Rd Unit 308, 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.
Under pen
are true.
eclare that I have read the foregoing document and that the facts stated in it
March 3, 2023
Signature
Nikolai O'Connor
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
this 3rd day of March , 20_23_b y Nikolai O'Connor
Produced ID Florida Driver License
Form of Identification
/Personally Kn#wn
{bog·l{or4. This notarial act was an online notarization
(NOTARY SEAL)
Signature of Notary Public
Penelope Harms
Name of Notary, Typed, Printed, or Stamped