David Gray (2)MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
OFFICE OF THE CITY CLERK
Email:BC@miamibeachf.gov
Telephone:305.673.7411
RECEIVED
JU 26 2024
CITY UF MIAMI BEACHOE:Err CLERK
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):Li a resident of the City of Miami Beach for six months or longer.
Home Address.351 r@ +Co AAt a,(3It0
~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).
are or osmess a9'DGett19sic€
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[]1am a full-time employee of a business (for a minimum of six months)and I am based in,st0
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 •re true.
''l ~.ct 7-2524
Signature
D@vb _eAy
Printed Name
Date