Thomas P. Richerson RECE!VED
MIAMI bEAu-i FEB 272024
City of Miami Beach CITY OF MIAMI BEA
1700 Convention Center Drive �' F!CE CE •TNE_Ctlti CLERK
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email:BCc@niiarnibe-__
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),
as (check (J) all that apply):
✓ I am a resident of the City of Miami Beach for six months or longer.
Home Address: 6450 Collins Ave, PH1, Miami Beach, FL 33141
riI 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:
Business Address:
I I 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:
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
stated in it are true.
�G p/ 2/25/2024
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Signature Date
Thomas P. Richerson
Printed Name