David GrayCity of Miami Beach
1700 Convention Center Drive
Miami 8each, Florida 33139
RECEIVED
JUL 14 7023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email:. BC@miambeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH TH E CITY OF MIAMI BEACH
! am in complian ce with the affiliation requirement of Miam i Beach City Code Section s 2-22 (4),
as (check (/) all that apply):
~ am a resident of the City of Miami Beach for six months or longer.
Home Address: 355 fart) o 2 Hpy [sir F 3;l4
~ave 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 ot Business.Pe'' > (' L)Sare
susmness Address:_S8 15. KA1Sc» ta (Au T 331to
'
[] 4am a full-time emp loyee of a business (for a minimum of six month s) and I am based in an
office or other location of the business that is physically located in Miam i Beach (for a
minim um of six months).
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"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" m eans any sole proprietorship, sponsorship, corporation , limited liability company,
or other entity or business association.
Und er penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in.it are true. ] !-»"9 Sign ature >
TA)LO. GA}
Printed Nam e
Date