Yechiel Ciment 12/31/23Y
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M IAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673 .7 411
AFFIDAVIT O F AFFILIATIO N W IT H THE CITY O F M IA MI BEACH
STATE O F FLO RIDA
CO UNTY OF MIA M I-DADE
I am in com pliance with the affiliation requirem ent of M iam i Beach City Code Section s 2-22 (4), as (check
(/) all that apply):
o I am a resident of the City of Miam i Beach for six months or longer.
ore Aaae./lo]_w/= tee oe _Il . 1/y o_cl
'
o I have an ownership interest (fo r a minim um of six m onths) in a business established in the City of
M iam i Beach (fo r a minim um of six months).
Nam e of Business _
Business Address _
o I am a full-tim e em ployee of a business (fo r a m inimum of six m onths) 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).
Nam e 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.
t I have read the foregoing docum ent and that the facts stated in it
t/1/0a2
Date
Printed Nam e
NOTARY
Sworn to (or affi rm ed) an d subs cribe d befor e m e, by mean s of physical presen ce or a online notarization,
?1 a Jan uary ,o22», echiel Giment
crotwami seae soarr c omm v ee veno,t= = E14,a1471„4a4RA fj g: COMMISSION # HH 165705 FL Driver's License [i;;_ ,3,i PRES: December 14, 2025
Form of Identi fication "7 5.$ Bonded Tu Notary Pubic undenwiers
Personally Known
X Produced ID
se.@,Ple, harles J D' gostin
(NOTARY SEAL)
Nam e of Notary, Typed, Printed, or Stamped
X
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