Maceo HallM IA M I BEACH
City of Mi am i B each
1700 Convention Center Drive
Miami Beach, Florid o 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
REC E IV ED
MA R 12 2024
CI TY OF MIAMI BE A CH
OFFICE OF THE CITY CL ER K
AFFIDAVIT O F A FF ILI A T IO N W ITH THE CITY O F MIA M I BEA C H
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4)
as ( check ( ✓) all that apply):
l/] lam a resident of the City of Miami Beach for six months or longer.
Home Address: 5500 Collins Ave, MB, FL, 33140
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: _
Business Address: _
D 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
Ere ta G--
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