Jane HayesMIAMI BE
City of Miami Beach
1700 Convention Center Drive
Miami Beach,Florida 33139
RECEIVED
AUG 02024
CITY OF MIAMI BEACHOF[IO·ErrCLERK
OFFICE OF THE CITY CLERK
Email:BC@miamibeachfl.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 rk (✓)all that apply):
El I am a resident of the City of Miami Beach for six months or longer.
Home Address._Coot {ate 'he_
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
stated •it are true.'
Si Date
Printed Name