Rina BassCity of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCemiamibeachfl.qov
Telephone: 305.673.74 1 1
I am i
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AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
n compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 1A)
i
as (check (,/) all that apply):
am a resident of the City of Miami Beach for six months or longer.
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Home Address: 0L1M; b('�Y?
❑ 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).
El
Name of Business:
Business Address
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 P hysically located in Miami Beach (for a
minimum of six months).
Name ot 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
or other entity or business association.
limited liabilit
Under penalties of perjury, I declare that I have read the foregoing documen
stated in, it are true.
i nature
Lit:
Printed Name
y company,
t and that the facts