Mark BrillA A //Al fi•y· \ i L'\ . ·/ \ 1·. ii{ i
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeach!l.gov
Telepho ne: 305.6 73.74 11
RECEIVED
AUG 10 2023
CITY OF MIAMI BEACH
OF FICE OF HE CI TY CL ER K
AFFIDAVIT O F AFFILI A TI O N WITH THE CITY OF MIAMI BEACH
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
{am a resident of the City of Miami Beach for six months or longer.
Home Ares_I_ q_1 _,tote p@f 4B ge 33///
/
]] have an own ersh ip interest (for a minimum of six months) in a business establishe d in the
City of Miami Beach (for a minimum of six months).
Name of Business: H f6, L.
susmess Address, 192,-9< (bra_oqke,_r/'_re__33y//
l am a full-time employee of a business (for a minimum of six months) and I am based in an
offi ce or other location of the busin e ss that is physically located in Miami Beach (for a
minimum of six months).
Name of Business: -------------------------
Business Address. too
Ownership Interest" me ans the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a businoss.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts $@ itae,pf,, • e]
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Signatur~ Date T r " - ' Mt#CI y -
Printed Name