Elisheva Rogoff 06/30/2206/30/2022 06/30/2022
5/2/2021 06/02/2019
05/24/2021
5/24/2021 Digitally Signed/ER
5/24/2021
5/24/2021
Received May 24, 2021Office of the City Clerk
IA/I
City of Mi am i Beach
1700 Convention Center Drive
Miami Beach. florid0 33139
OFFICE OF THE CIT CLERK
Email: Ç@miaribeachf_go
Tel ep hon e: 30 5.6 7 3.74 11
AFFIDA VI T O F AF FILIA TIO N WITH THE CITY OF MIAM I BE ACH
STATE OF FLORIDA
COUNTY OF Mi am i -D ade
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[g 1am a resident of the City of Miami Beach for six months or longer.
[] 1have 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).
[] lam a full-time employee of a business (for a minimum of six months) and l am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
"Ownership Interest" means the owners hip of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"B usin ess" means äy sole proprietorship, spon s orship, corp ora tion, 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
state~ Ç /;y-t /c!.\
Signat é Date T- 7 eo
O Printed Name TT
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or [J online
notarization, this 2 4 th d ay of May _,20_21_by
Elisheva Rogoff (City of Miami Beach Board/Committee Member).
X Produced ID FL Drivers License
Form of Identification
Personally Known
Ciac 'geo
Signature of Notary Public
CharlesJ. D'A g ost in
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Ch ar les J. DAgostin
NOTARY PUBLIC
STATE OF FLORIDA
XC3ES com# GG16s171
Expires 12/14/2021
Committee for Quality Education in Miami Beach
5/2/2021
X
Received May 24, 2021Office of the City Clerk