Elisheva Rogoff/V\ I AM I B EAC
City of Miami Death
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
EMIL 9C&-M1aMibe3Pbfl
Telephone; 365 673 7411
RECEIVED
DEC 01 2021
CITY OF MIAMI BEACH
OFFICE OF 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 (/) all that apply):
Ea-11"am a resident of the City of Miami Beach for six months or longer
Home Address: 5 c�,c)3
13 1 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:
0 1 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:
00wnership interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or mom of the outstanding capital stock) in a business.
`Businesso means any sale proprietorship, sponsorship, cotpotalion, limited liability
company, or other entily or business association,
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
true,
Signature bate
F— I is-ke-ok
Printed Name