Samuel RabinMIAMI BEACH
RECEIVE®
City of Miami Beach DEC 01 2021
1700 Convention Center Drive
Miami Beach, Florida 33139
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICE OF THE CITY CLERK
Email Bc.@rmiaJb.each "-Dpy
Telephone: 305.673.741 1
I am in compliance with the affiliation requirement of Miami Beach City Code Sections -22 (4),
as (check (./) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
HomeAddress:
❑ 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).
Business Address:
❑ 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:
"Ownership Interest" means the ownership of fen percent (10%) 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 perjiy, f declare that I have read the foregoing document and that the facts
stted"fin it are true.,,,,,,,
Signature
t
Printed Name
Ili A-1
Date