Jonathan BeloffMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: Rq@njqm(bpqphfI
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Telephone: 305,673,7411
RECEIVED
DEC 01 2021
CITY C)F MIAMI BEACH
OFPC'-i:.�- THE CITY CLERK
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 (V) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address:
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).
S> A,Name of Business: Z C\ L 0-1-W,
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Business Address:
1c,
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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 (10yo) 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
st din it are true.
/2 2
sinature Date
Jonathan D. Belloff
Printed Name