Chana Levin-EisnerlAMIBEAC
City of Miami Beach
700 Convention Confer Drive
Miami 8each, Florido 33139
O FFIC E OF THE CITY CLERK
Emal BG@mam±be ach1\ gov
Telephone 305.673.7411
RECEIVED
APR 24 2023
C ITY O F M IA M I BEA C H
O FFIC E O F TH E CI TY CL ERK
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)
) lam a resident of the City of Miami Beach for six months or longer.
4101 Pine Tree Dr. Apt 804, Miami Beach, FL. 33140
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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 sx months)
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I lam 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 propnetorship, sponsorship, corporation, limited liability company, or other
entity or business association
Under penalties of perjury, 1 declare that I have read the foregoing document and that the facts stated in it
e s Pf_., 4[23/23
I I Signature
Chana Levin-Eisner
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of u physical presence or o online notarization,
osao»at. JC olo» IHA.a LA LL_er
(City of Miami Beach Board/Committee Member)
Produced ID
Form of Identification
Personally Known
i · 1!4 4 I id_fKA ire1 1.
'. ESTHER APPEL f!'~~\Nolary Publlc-S1aia of Florida
Zr ? Commission 4 G6 347270
};=? My Commission Expitos
"is" August 15, 2023
Signature of Notary Public
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(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped