Brittany FawM !AM IB E
City of Miami Beach
1700 Convention Center Drive
Mi am i Beach , Fl orida 33139
O FFIC E O F TH E C ITY CL ERK
Em ail: BC@miamibeachfl.gov
Telephone: 305673.7411
RECEIVED
MAY 2 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):
ti lam a resident of the City of Miami Beach for six months or longer.
Home Address Lo0. (Colins Aye. ])8 Mi@mi (ch, EL 3,3)'40
□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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Py,1mes,S, J\([rs,
□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
are e. 5/44 a '}0/7004 , fa) 9la,\Aua,2
Signature Date '
ri ±± any f60
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed betore me, by means of physical presence or online notarization,
this_day ot_1] ,2023_ PY±hoop Lyon fa
(City of Miami Beach Board/Committee Member).
J ecaeeso f pl
Form of Identification
~ ERIC DI SANTO
« , Commisslon Ko. H 099122
3}g Exp#res March 1, 2025
«" oded thu Bud9At Notar Sr vices
Signature of Notary Public rs. <Yono
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped