Sam Rabin Sep 2022 (2)MIAMI BEACH
RECEIVED
City of Miami Beach 0 C T -6 2022
1700 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICF nr THE CITY CLERK
Email: BC ac�'tif_c ov
Telephone: 305.673.7.411
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
(J) al ,.that apply):
I am a resident of the City of Miami Beach for six months or longer. r� q
Home Address 0 ttt ..w.-�e-oQe— Ate) .F.. Ct` "` I' t �i
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
n 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 (109/6) 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 penalperjuuyr declare that I have read the foregoing document and that the facts stated in it
are true „r�
Sigppwr Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of" yh si al presence or o online notarization,
this day of 20bY 1 y i
c
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Personally Known
i ature o otary public
poor-')
Name of Not4ry, Typed, Printed, or/Stamped
r3?�Y"ti•; JACQUEUNEPAYA
MY COMMISSION # GG 949M
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