John GardinerM IA M I BEACH
City of M iam i Beach
l 700 C onvention C enter Drive
M iam i Beach, Florida 33 13 9
REC EIVED
JAN 24 2024
CITY OF MIAM I BEACH
O FFIC E O F THE CITY C LER K
O FFIC E O F TH E C ITY C LERK
Em ail: BC@miamibeachfl. gov
Telephone: 305 .67 3 7411
AFFID AVIT O F AFFILI ATIO N W ITH THE CITY O F MIAM I BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check ( ✓) all that apply):
[/El am a resident of the City of Miami Beach for six months or longer.
Home Address: 28 W Rivo Alto Dr M iam i Beach FL 33139
D 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).
Name of Business: a
Business Address: ------------------------- □I 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 physically located in Miami Beach (for a
minimum of six months).
Name of Business: -------------------------
P/I[f9, (](fo S,-
"O wnership Interest" m eans the ownership of ten percent (10%) or m ore (including the
ow nership of 10% or m ore of the outstanding capital stock) in a business.
"Business" m eans any sole pro prietorship, sponsorship, corporation, lim ited 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
stated in it are true.
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