Sara VelasquezM IAM I BEACH
C ity of M ia m i B e a ch
17 0 0 C onventio n C enter Drive
M ia m i Beach, Florida 33 13 9
O FFIC E O F TH E CI TY C LERK
Email: BC@miamibeachfl.gov
Telephone: 30 5 .6 7 3 .7 411
RECEIVED
APR 04 2023
CITY 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):
rJ I am a resident of the City of Miami Beach for six months or longer.
Home Address
□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.
Date
Printed Name
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are true. 'fiM {¾ ~
Signature
3a Vel a 9 e z-
NOTARY
________ (City of Miami Beach Board/Committee Member).
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or on line notarization,
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Form of Identification
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Signature of Noia/ Pi
Name of Notary, Typed, Printed, or Stamped