Ana Ceci VelascoM IA M I BEACH
City of Miami Beach
17 00 C onvention C enter Drive
M iam i Beach, Florida 33139
O FFIC E O F TH E C ITY C LERK
Email: BC@ miamibeachfl.gov
Tel ep h one: 30 5.6 7 3.7 411
RECEIVED
APR 13 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 an, in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
121 I am a resident of the City of Miami Beach for six months or longer.
Home AddresZ455 Flamingo Drive, #404, Miami Beach, FL 33140
□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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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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[Is[fess ((dfeS
"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
ey 'y or b iness association.
declare that I have read the foregoing document a that the facts stated in it
Signature~-< .
1 Gao/lre
Printed Name
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
o» 2h o ow. Anl ao2. mAn o Co lic- / @cO
________ (City of Miami Beach Board/Committee Member).
fl (Onve1s Lonu€ Produced ID
Form of Identification
Personally Known
Name of Notary, Typed, Printed, or Stamped-