Igor ShteyrenbergMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email SC(a'mlamibeacli l.00v
Telephone 305 6-,3 7411
AFFIDAVIT OF AFFILIATION WiTH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (.r) all that apply),
❑ i am a resident of the City of Miami 'Beach for six months or longer.
Home Address:
El 1 have an ownership interest (for a minimum of six months) in a business established in the
Citf of Miami Beach (for a minimum of six months).
Name of Business:
Business Address:
am a full-time employee of a business (for a minimum of six months) and I am based in an
offr„e or other location of the business that is physically located in Miami Beach (for a
mmimum of six months).
'Marne of Business: 1"A0W1_1�1_1Wfi11 `vim f0m0ft—
Business Address +nk f V.(* TXa Q4, /Ad WS, 14;444 fl- 5 3 t4
`'Gwrerstup Interest" means the ownership of ten percent (1 D%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business' rnearrs any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Under Menalfies of perjury, I declare that I have read the foregoing document and that the facts
Stated it it are true.
Signaturt
Printed Name
C/s/r3
Date