Jose Smith RG@ETOPD
1 \� 1I ,AM I BEACH F4BI45-2024
City of Miami Beach
1700 Convention Center Drive 'Orr' 11�
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email. BCmiamibeachfl gov
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
ass,(check (J) all that apply):
LDS I am a resident of the City of Miami Beach for six months or longer.
Home Address: u 7 N 5 F-1 C) R E V
IN 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: D 5 C .J M l''r A T1-0 a N EY
Business Address: p-•�.. ;G �
LN 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: l 05'6- 5r4 t 'T �1 � ) R N Y
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 foregoing document and that the facts
in it are ue.
Z) )51Z y
l t Date
05• - SM\TH
Printed Name