Prakash KumarM IA M I BEACH
RECEIVED
JAN 12 2024
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7 411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in com pliance with the affiliation requirem ent of Miam i Beach City Code Sections 2-22 (4),
as (ch eck (/) all that apply):
~m a resident of the C ity of M iam i Beach fo r six months or longer.
Hom e A ddress,3 3 Collins aven ue ( 1204),M.B each , FI- 33139
D I have an ownership intere st (fo r a minim um of six months) in a business established in the
C ity of M iam i Beach (fo r a minim um of six months).
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[3[JS[fess (]Hf@SS.
D I am a full-tim e em ployee of a business (fo r a minim um of six months) and I am based in an
office or other location of the business that is physically located in Miam i Beach (for a
m inim um of six months).
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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, limited liability company,
or other entity or business association.
Under penalties of perjury , I declare that I have read the fo regoing docum ent and that the facts
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Signature Date
P rakash kum ar
Printed Nam e