Matthew LandMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCQrnIamibeachfl.goov
Telephone: 305 673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am /.k
liance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (c) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address: 1450 Lincoln Rd Apt 307, Miami Beach, FL 33139
❑ 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 (105/6) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
Susiness" anys proprietorship, sponsorship, corporation, limited liability company,
or of itv or business ssociation.
Under penalties of perjury, I d�clare that I have read the foregoing document and that the facts
stated in it are true.
6/26/2023
Date
Matth
Printed Name