Dennis Scholl MIAMI BEACH
City of Miami Beach RECEIVED
1700 Convention Center Drive
Miami Beach, Florida 33139 FEB 2 8 2024
OFFICE OF THE CITY CLERK CITY OF MIAMI BEACH
Email: BC( miamibeachfl.gov OFFICE OY"'`-IE CITY CLERK
Telephone: 305.673.7411
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 (✓) all that apply):
17 I am a resident of the City of Miami Beach for six months or longer.
Home Address: 0260 I (n I(&.t p-.(l )Li/L1IU 4 3 oil is L1lXY1 i 6_d 1c
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:
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:
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 dec9ar tha ave read the foregoing document and that the facts
stated in it a true.
vtA/NA_ 602-)a 6)020 02,
Signature Date
3efli Sal 0 1 I
Printed Name