Sophie RingelCity of Miami Beach
170 Convention Center Ddve
Miami Beach, florida 33139
OFFICE OF THE CITY CLERK
Email. BC@mamuteach!gos
Telephone: 305.673.7411
RECEIVED
MAY 09 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUN TY OF MIAMI-DAD E
I am in compliance with the affiliation requiremen t of Miami Beach City Code Sections 2-22 (4), as (check
/) all that apply).
lam a resident of the City of Miami Beach for six mon ths or longer
ome Address 23s bole 'ho,oat. po±.to Moo._2d,333/40
[ Ihave an ownership interest (for a minim um of six months) in a business established in the City of
Miami Beach (for a minimum of six months).
[$qr ff P{Sf.bi.or«or»
Pf4f,«, jkfS,3....--or«or
l am a full-time employee of a business (for a minimum of six months) and l am based in an office or
ot her location o f th e busine ss that is physically located in Miam i B e ach (fo r a minim um o f six months).
ere se es Cleon vi ch
23as Z ke Pa coos/ hp.a, hi@ ,7 33/o B u sin e ss Address
"O wner s hip Inte rest" m e ans the ow n ersh ip of ten p e rcent (10 %) or m or e (inc ludin g the ownership of
10 % or more of th o outst an ding cap ital stock) in a busine ss
"B u sine ss" m e a n s an y so le proprietorship, sp o nso rship, corporation, m ute d iabity company, or ot h e r
entity or bu sin e ss associa tio n
U n d er pen al tie s o f pejury. 1 de9lye that I ha ve re ad th e fore goi ng do cum en t and that the facts stated in it
«" .eh o l5Ts
Signature Date
5eh« n4el
P rint ed N a m e /
NOTARY
S w o rn to (or affirme d ) an d su b scr ib e d before m e, by m e a ns ophysical pr esence or to online not ar ization ,
0 K. V\..0 ,~-,,_ _ .2fa a /fol as23
City of Miami Beach B o a rd /C om m itte e Me m b e r)