Beverly HellerMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach , Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@mlamlbeachfl.gov
Telephone : 305.673 .7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as <9eck (✓) all that apply):
[M' I am a resident of the City of Miami Beach for six months or longer.
Home Address: ,f"9 l lo LA b(;f'l..e.. '\) (l.-. \\A"l p.J.,,, t ~~, ft-3 3 I ½ 0
D 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).
Name of Business: ------------------------
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: ------------------------
Business Address: ------------------------
"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 true.
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Signature Date
B<.w''l t-\e\\<.c
Printed Na
RECEIVED
MAY 30, 2023
OFFICE OF THE
CITY CLERK