Rachel UngerMIAMI BEACH
City of Miami Beach 1 700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
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):
� I am a resident of the City of Miami Beach for six months or longer.
Home Address: 4 z. 4 � fo'b t" Ave . M \ o. m \ 'r;eo. c"'1 , f �o, '-\ 0 D I have an ownership interest (f or 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: __________________________ _
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 (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 perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
sJSur'if?::-5
Printed Name
Date \
Received December 2, 2021
Office of the City Clerk