Igor Shteyrenberg Sep 2022M IA MI B EACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email C@miamibeachf._gov
Telephone: 305.673.7411
RECEIVED
JUL 21 2022
CITY OF MIAMI BEA CH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
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 ):
o 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).
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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. /3A+$ J (Rn (€r t
Business Address_ [ _Éyß Ti£G D,@Ar @,u 33140
"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 pen
are true.
Signature
ies of perjury, I declare that I have read the foregoing document and that the facts stated in it
/4/1
Date '
Printed Name
NOTARY ln to (or affirmed) and subscribed before m~ means 0~7'ical presence or o 07line notarization,
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