Jack BenvenisteCity orml4no 90alch
17 00 colivemion txater Privc
Miami Seatk floncla 33139
00iff"OFTHE CM CLURK
RECEIVED
DEC 01 ZOZI
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDA)LIJOF AFFIL16TI,ON WITH,THE CRY OF MIAMI Sk&;h
I am in compliance with the affiliation requirement of Miami Beach City Code Sections: 2-22 (4),
as (check (,/) all that apply)
1--y
P I am a resident of: the City of Miami Seadh for six months or longi
Home Addrew: cy 0 17 IV t'&- tC Ve-, 4tz'
fa e el -T 41v
0 -10 -)rave an ownership interest (for a minimum) of six months) in a business 6stablisbed In the
City of Miami Seath (tot a minimum df' six months).
Name of Business.- '-f - 21.1'. 1
Business Address / a / 1-.- ZZ S't z -.2'z & A 2 L4 Z�- & .e 1>4fz-- "
lama full-time employee of'a business (for a minimum of six rnoriths) and I am based in an
office or other location of thebusiness that is physically located in Miami Seach (for a
minimum of six Months)
Name of Business:
'Ownership triletest' meas the ownership of ten percent (10%) or n (ineJutlitV the
ownetship of 10% or more of the ovIstanding capital stock) in a husineSs,
"Sus)ness* means any sola proprietorship, sponsorship, cwpoiation, limited liability
corapariy, or other entity or business association,
Under penalties of peury. I declare that I have read the foregoing document and that the facts
stated in it are,true,
nature Date
Printed Name,