Jane HayesMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
M iam i Beach,Florida 33139
RECEI L__·--·'
JAN 16 202
CITY OF MIAMI BEA•OFFICE OF THE oy,!CLER
OFFI CE OF THE CITY CLERK
Email:BC@ miam ibeachfl.gov
Telephone:305 .673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in com pliance with the affi liation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (✓)a II that apply):
~m a resident of the City of Miami Beach for six months or longer.
Hore Aaarecs.boo\?caia
D I have an ownership interest (for a minimum of six months)in a business established in the
City of Miam i Beach (for a minimum of six months).
Nam e of Business:·-------------------------
Business Address:._
D I am a full-tim e 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}.
Nam e of Business:._
Business Address:_
"O wnership Interest"m eans the ownership of ten percent (10%)or more (including the
ownership of 10%or m ore of the outstanding capital stock)in a business.
"Business"m eans any sole pro prietorship,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 i are true.
/L5-26a5
Date'
Printed Nam e