Michael Zilber1/\4l £AC
City of Miami Beach
1700 Convenlion Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Em ail:. BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
M4AR 20 2023
CITY OF MIAM I BEA CH
OFFICE OF THE CITY CL.ERK
A FFIDAV IT O F AFFILI A TIO N W ITH THE CITY O F MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MI A MI -D AD E
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
f lam a resident of the City of Miami Beach for six months or longer.
tor e Asa.. [o qlyl}u_A)s,_A 'or«d &«,L s3s
□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 _
[/J,[[,, (fr]fCS,_urn-
□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 _
p[I,[f@,, J\(](]TC,or«or«or.
"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 penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
I/he; er=toe
Si gn at ure Date
/he] G. 2l.
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or u online notarization,
dO er or la(_.oz pl1 o 2wc
(City of Miami Beach Boar 'Committee Member).
Produced ID
\ Form of Identification_
A Personally Known
Sign
Nam
TERESA RMAIREZ
Notary Public • State of Florida
Commission # HH 319108
My Comm, Expires Oct 5, 2026
Bonded through National Notary Assn.
(NOTARY SEAL)