Samuel RabinM IAM IBE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf].gov
Telephone: 305.673.7411
RECEIVED
FEB 22023
CITY OF MI AM I BEA CH
OF FICE OF THE OITY CLERK
AFFIDAVIT OF AFFILIATION W ITH 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):
IZl I am a resident of the City of Miami Beach for six months or longer.
Home Address9 Island Avenue, #2101, Miami Beach, FL 33139
□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).
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"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.
care that I have read the foregoing document and that the facts stated in it
2/2/2023
Date
Samuel J. Rabin, Jr.
Printed Name
NOTARY
Swom to (or affirmed) and subscribed before me, by means of physical presence or a online notarization, » a, (bv «y02s Sol 1. 24o1.T- ... I I -----
________ (City of Miami Beach Board/Committee Member).
Produced ID
Form o
ersonally Known