Lilly de la MotteMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florid 33139
OFFICE OF THE CITY CLERK
Emai l: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
MAR 20 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
(✓) ali that apply): + lam a resident of the City of Miami Beach for six months or longer.
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□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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a 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).
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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 business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
" BA( 3/n/23
Signature Date
lllu de la Viole
Printed Name 7
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o~hysical presence or online notarization,
ooh .co o«MM asp s» La l4 de [a Motl
________ (City of Miami Beach Board/Committee Member).
Produced ID
- / Form of Identification
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Name of Notary, Typed, Printed, or Stamped