Dennis SchollM IA M IB E A C
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ai l: BC @m iam i b eachfl.goy
Telephone: 305.673.711
MAR 31 20Z3
C/Ty OF MIAM I 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):
lam a resident of the City of Miami each for six months or lo99,\ p}
o -A as » 2001 Ai.lit ill/2 34 3 l (e#»
□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).
[/are [ P[JS[eS5
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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 ii; physically o ted in M iam)'each tlor m T of six month!~
re -e n Oo t u A @$)
sosness Aa@recs ,)) Luu» "UH"+ (son {or
"O w nership Interest" m eans 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 peal ·es of perjury, I
are true.
«d
have read the foregoing docume t and tha the facts stated in it
' Signature
D54/1953
I
$1 L
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of a'physical presence or n online notarization,
2$'a «Ms-chi_.zoo%y
(City of Miami Beach Board/Committee Member).
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--Personally Known
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