Carolina JonesMI A MI B
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
RECE IVED
A R 21 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):
IZl I am a resident of the City of Miami Beach for six months or longer.
Home Address 1101 Stillwater Drive 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 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 (tie$ of/perjury, I de~lare that I have read the foregoing document and that the facts stated in it
are true. J \ l 3/3/23
-------------- Signature Date
Carolina Jones
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
+0 day a M\up .2o3 (ran }uned
_________ (City of Miami Beach Board/Committee Member).
roaocaao Pt 0vu r)
y7de
a / = Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped