Adrian GonzalezC ity o f M ia m i B e a ch
1700 Convention Center Drive
Miami Beach, Florida 33139
O FFIC E O F TH E C ITY CL ERK
Em ail: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
MAY 11 2023
CITY O F 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
(0 9l that apply).
e am a resident of the City of Miami Beach for six months or longer.
Home A«dress. aooo keoreLy D u
□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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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 -------------------------
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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 penalti
are true.
Signature
, I declare that I have read the foregoing document and that the facts stated in it
c1pl2>
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
ea co»or_N}; 3 Iron eon6l2 wwn,, ·ijiA.Mi;}" (City of Miami Beach Board/Committee Member). s $], ,
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Name of Notary, Typed, Printed, or Stamped