Mohammed IslamM IA M I BEACH
RECEIVED
JUN 01 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CL ERK
City of Miami Beach
1700 Convention Center Drive
Miami Beach , Flor ida 33 13 9
OFFICE OF THE CITY CLERK
Emai l: BC@m iamibeachf.gov
Teleplame:. 35. 673.7411 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in co m pliance wi th the affi liation requirement of Miami Beach City Code Section s 2-22 (4),
as (check () all that apply):
E] 4am a resident of th e Ci ty of Mi am i Beach for six month s or long er.
a , s + >
H om e Addres s:I 0A,Bcvi1!3 .pr,4± 2> MA aa el h3341
~ave an ow nership interes t (for a minimum of six m onths} in a busines s established in the
City of Miam i Beach (fo r a minimum of six months).
Name ot Business:. _]sis ?clha s'
Business Addre ss:11 4 - 13, 61ST $feat, t-fa Ie.& €-3314
0 I am a fu ll-tim e em ployee of a business (for a minimum of six months) and I am based in an
office or other loca tio n of the business that is physica lly loca ted in Miami Beach (for a
mi nimum of six mont hs). ~
eme oroses._ Sc)k goeplsje
Business Addre ss: _Sc_& Cs bo&ye
"O wn ersh ip Intere st" means the own ersh ip of ten percen t (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" me ans any sole proprietors hip, spo nsorship, co rporation, limited liability company,
or other entity or business association.
Under penal~pe~ury , I dec lare that I have read the fo regoing document and that the facts
stated in i\ a~ tru e. _
- t (_ o[o]2s23
Signature ~ _ \) Date
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Printed Nam e