Cori RiceMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: Bcc@miamibeachfl.gov
Telephone: 3 05.673.7'41 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
11 1 am a resident of the City of Miami Beach for six months or longer.
Home Address:
19 1 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: Fontainebleau 11 Properties 2116LLC
Business Address: 4401 Collins Ave., Miami Beach, FL 33140
❑ 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 fen percent (1096) or more (including the
ownership of 101 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 afire true.
�A7l,I
Signature
Printed Name
Date