Mark RabinowitzMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
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Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK DEC 06 2021
Email: B„ G�a7miamibeaahfl.aov
Telephone: 305.673.741 1
CITY OF MIAMI BEACH
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEAtIWICE OF THE CITY CLERK
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:
❑ 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:
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).
I any the CEO and CMO of the Miami Beach Community Health Center, a Federally Qualified Community Health
Center that provides medical care on a sliding fee scale to the City of Miami Beach community.
Name of Business: Miami Beach Community Health Center
Business Address: 710 Alton Road & 1221 71st Street, Miami Beach, FL
"Ownership Interest" means the ownership of ten percent (909,6) 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.
k- 12/05/2021
Signature Date
Mark Rabinowitz
Printed Name