Robin Jacobs (2)MiAI' I BEACH
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IN,a,.. yweA ifr41 3311 N
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I am in compliance with the affaalion requiremenl of Miarm Beach £Ity Code Sediom 2.22 (4).
es ;c ck i l I al thal appty).
l.I em is resident of the City of M(eml Beach for six morghs or bn9er7.� v1�S l ! L— I f O
Home Address.
7-`— -i.
2/1'
have an ownership interest (tor a Minimum of sue rnonlhs) In a business established in Me
City of M.am( Beach Jim a morntilln Of ea Mont!").
Name of Business: 3(ls C Lii` �`a
Business Address:
G , 1� 1,.l�a M , 'React,
❑ I am a lull -tone employee of a business (for a minhnum of six months) and lam based in an
office or other location of the business Mal Is physically located II Miam Beach IfOr a
minimum of sa months).
Name of Business:
Business
'0wrws1w hnterest' means Ole ownership of ten percent (10%) or more (inckrdrng the
ownership of 10% or more of Me oufsfancf V capita( sfock) in a basufess.
1Busuiess" means any sole psgorieforshilx sponsorsfap, corporatUo Anwaf kabAfy company,
Of mfnerentHy or business association.
under penalties of perjury. 1 declare that I have read the foregoing document and MM Ma fads
staled n) are true.
sZ261- 2a61-3
Sigh ure Date
l✓ r.r Glf r�r
Printed Name
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