David Gray (3)MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
RECEIVED
JUL 26 202
CIT UF MIAMI BEACHEE'yr.rrC1ERK
OFFICE OF THE CITY CLERK
Email:BC@miamibeachf.gov
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):Li a resident of the City of Miami Beach for six months or longer.
Home Address:351 r@Co 9 NAt At,(S3It0
~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 posess 2a9'DGr@Y19nGG
sues a@res»?575few-oDerrnrvKao,f
[]1am a full-time employee of a business (for a minimum of six months)and I am based m lt
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
[]qf]9 (f PIS/[es,-
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.
..d.c 7-2524
Signature
DUD _pay
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Date