Carmen DatorreM IA M I B E A C H
Ciy of Miami eh
1700 Con vention Center Dr ive
Miam i each , Florid 33139
OFFICE OF THE CITY CLERK
Em ail: BC@mlamibeact.go
Teleph one:. 305.673.7411
RECEIVED
JUN 27 2023
cI OF MIAMI BEACH},
OFFI C E OF TH E CITY CLER
AF FID AVIT OF AF FILIATION WITH THE CI TY OF MIAMI BEACH
l am in com plian ce with the affiliation requiremen t of Miami Beach City Cod e Secti ons 2-22 (4),
as (check (/) all that apply): 'fl I am a resident of Iha City of Miami Beach for six mo nths or longer.
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I] Ihave 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 or use. _en»a h-j
usmoss Asa r.._'_j e Ms F33/0
[Sy 1am 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: @l o
Business Address: ----------------------
"O wne rsh ip Interest" m oan s 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.
penalties of perjury, I de
te in it are true.
that I have read the foregoing document and that the facts
Date ' 7
Printed Nam e