Jose HernandezMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(WmiamibeachL.
Telephone: 305.673.741 1
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 (check (./) all that apply):
LTJ I am a resident of the City of Miami Beach for six months or longer.
Home Address: 630S �.d;C(-eeG< 0,- 14.9L
'73114 1
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: '3-v-0` W41 iMc-^c.SeGeo,e , L_I-
C_
Business Address: 56.0'L a,, V'0'.^r
2f 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- �gv <C-,, c- c t z- 6o,i t—
Business Address:
`Ownership Interest" means the ownership of ten percent (109,S) 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.
�Z 31 2023
SignatLW Date
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Printed Name