Jane Hayes (2)M IA M I H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@m iamibeachfl_gov
Telephone: 305.673.7 41 l
RECEIVED
JAN 13 2023
CITY OF MIAMI BEACH
OFFICE OE TH E CITY CL ER K
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):
e I am a resident of the City of Miami Beach for six months or longer.
Hore Aadress 3o\ }caice $he
□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.
nalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
/la0a%
Date T> °
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
e 1 a or 00nu6 49,,20is Q@n Ht«,
_________ (City of Miami Beach Board/Committee Member).
Ionur ton€ Produced ID
Form of Identification zr- Signature of Notary Public l l In
Name of Notary, Typed, Printed, or Stamped