Ray BreslinMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: 13C(cDmiamibeachfi.aov
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 (check (✓) all that apply):
Z_ I am a resident of the City of Miami Beach for six months or longer.
Home Address:
N
M? 6,0 yd��
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: 1)68— R'Llysd J l 3l
Business Address: �--, S w ZT`, �� {"� (' (/� —(n �� j n
❑ 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 pen alti of perjury, I declare that I have read the foregoing document and that the facts
stated in it ar, rue.
Signature
L, 0j -
Printed Name
Date