Jonathan WelshMIAMIBE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7411
RECEIVED
MAR 16 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):
k I am a resident of the City of Miami Beach for six months or longer.
tore ares Io ?2 [old Aue 1
□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 tlat 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 penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it !2ht t 3poss.s
Sign ur Date ' "en Pl- Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online notarization,
we lo hay or _Moo_ _,ao».00ton Le/rh
(City of Miami Beach Board/Committee Member).
/ ecacao nvta c Lt_av C
Form of Identification
Personally Kn~~
Name of Notary, Typed, Printed, or Stamped