Moshe RothmanMI AMI'BEACH
City of Miami each
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
FEB - 9 2022
OFFICE OF THE CITY CLERK
mat: BC@mi amibeach.aoy CITY OF MIAMI BEACH
Telephone: 305.673.7411 OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMLBEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in com pliance with the affiliation requirem ent of Miami Beach City Code Section s 2-22 (4), as (check
(/) all that apply):
/ 1am a resident of the City of Miami Beach for six months or longer.
Home Address Aioi Pee Tea_ D. H)@O, Miam'i .¢acn, Fl
33140
a {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).
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lam a full-time employee of a business (for a minimum of sbx months) and I am based in an office or
other loca tion of the business that is physically located in Miami Beach (for a minimum of six month s).
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pus[fess (ddf%Sb»
"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" mea ns 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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Mo€ 'o TRN
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or a online notarization,
this day Of,lh )
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4Y COMMISSION # HM 165705
EXPI RES: December 14, 2025
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Produced ID
Form of Identification
Personally Known
(NOTARY SEAL)
Signature of Notary Public
Name of Notary, Typed, Printed, or Stam ped