Cheryl JacobsMIAN�l BEACH
RECEIVED
City of Miami Beach DEC 03 2021
1700 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICE' 0= HE CITY CLERK
Email: BC(2miamibeachfl.aov
Telephone: 305.673.7411
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 (J) all that apply):
XI am a resident of the City of Miami Beach for six months or longer.
Home Address:20 Island Ave Apt 707 Miami Beach FL 33139
❑ 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).
Name of Business:
Business Address:
❑ 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:
"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.
6bA
Signature
Cheryl H Jacobs
Printed Name
12/2/2021
Date