Dean CampbellCity of Miami Beach
17G0 Convention Center Drive
Miami Beach, Florid 33139
OFFICE OF THE CITY CLERK
Em ail. BC@miamibeachfl.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.
Hom e Address 9O0 Bay Drive 619, Miami Beach, FL 33141
□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 percen t (10%) or more (incl uding the ownersh ip of
10% or more of the outstanding capital stock) in a business.
Business" means any sole proprietorship, sponsorship, corporation, limited liability comp any, or other
entity or business association.
e that I have read the foregoing document and that the facts stated in it
March 3, 2023
Signa ture
Dean C
Date
Printed Name
NOTARY
Sworn to (or affirm ed) and subscribed before me, by means of rs phy sical presen ce or online notarization ,
-a° 9z ( this ' day or PLneg[_ 20by _peq r) @ ta_
_________ (City of Miami Beach Board/Com mittee Mem ber).
K)[wt Produced ID ✓Form of Identification
Person ally Known
l. =a /
f! PG. LISSETE MORALES 8%ji± Notary Pubic- state ot Florida 3.35/ commtsion G G 961479 %5f$ My Comm. Expires Mar 1, 2024
Bonded through National Notary Assn.
(NOTARY SEAL)
Signat ure of Notary Pub lic
LiSsse±e Morales
Name of Notary, Typed, Printed, or Stamped