Robin JacobsM IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email. BC@miamibeachfl gov
Telephone: 305.673.7411
RECEIVED
JAN 19 2022
CITY OF MIAMI BEACH
OFFICE OE THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEA CH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
tam a resident of the City of Miami Beach for six months or longer.
Home Address la05 Flam<o Dove_, fao«. be,F- 53o
/ 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_ go Pe{_. 305_ ca2eley
Business Address 400 Atfhv.r G~¿fe'i f?c! .5uAa 3°5 M¡<l.,..: feti.cli, FL 57 11/o
o 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
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si@aure Date
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Printed Name
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