Cindy Mattson (2)49
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City of Miami Beath
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCemiamibeachfi.go
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
1 am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as(deck (V) all that apply):
am a resident of the City of Miami Beach for six months or longer.
Home Address: � �� �
❑ 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)
office or other location of the business that is phys'i'cally located in
minimum of six months).
Name of Business:
Business Address:
and I am based in an
Miami Beach (for a
"Ownership Interest" means the ownership of ten percent (101/1o) or more (including the
ownership of 10010 or more of the outstanding capital stock) in a business.
"Business any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity cy b usiness association.
Under penaftie f perjury, I declare that I have read the foregoing document and that the facts
stated in it:e tr . �7
Signatu
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Printed Narhe
Date
5 a�