Mary KeinathM IAM I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF TH E CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7411
RECEIVED
MAY 30 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):
✓I am a resident of the City of
□I have an ownership interest (for a mihimum of six months) in a business established in the City of
Miami Beach (for a minimum of six months).
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[[JS[fess J(](]fess
□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 busit +ss ass ciation.
Under penal s
are true.
Signature
that I have read the foregoing document and that the facts stated in it
5-22-2
Printed Name
- Date
A nefi-
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
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Name of Notary, Typed, Printed, or Stamped