Jose HernandezM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7411
RECEIVED
JAN 12 2024
C ITY O F M IA M I BE A C H
OFFICE OF THE CITY CLERK
A F F ID AVI T O F A F F ILIATIO N WI TH TH E C ITY O F M IA M I BEA C H
I am in co m p lian ce w ith th e affi lia tion requirem ent of M iam i Beach C ity C od e S ection s 2-22 (4),
as (ch eck (/) al l th at apply):
[/1am a resid ent of th e Ci ty of Miami Beach for six m on th s or lon ger.
H om e A aaress 3 05 J..A• C eel Zc }
g, ha ve an ow ne rs hip interest (for a m inim um of six m onths) in a business esta blished in the
C ity of M iam i B ea ch (for a m inim um of six m onths).
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B u si ne ss A ddre ss:_0 s ± ele 4}
D I am a fu ll-tim e em p loyee of a business (for a m inim um of six m onths) and I am based in an
offi ce or oth er lo cat io n of th e busin ess th at is physically loca ted in Miami Beach (for a
m inim um of six m o nth s).
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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" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business assocation.
U n d e r pen al tie s of perjury , I decl are that I have read th e fore goin g docum ent an d that the fact s
sta te~d in i are e.
< L/1/202y
Sign~lure Date
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P ri nted N am e