Karen Edelstein (2)City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33 139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.Q01V
Telephone: 305.673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am in compliance with the affiliatql
as (check (V) all that apply),.
on requirement of Miami Beach City Code Sections 2-22 (4),
am a resident of the City of Miami Beach for six months or I,
Home AddressZ Z. W 'j
❑ I have an ownership
City of Mi"ami Beach
Pon
Business Address
i
oliger'.
interest (for a minimum of six months) in a business established in the
(for a minimum of six months).
El 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
IV
minimum of six months).
Name of Business:
Business Address:
"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 blusiness.
"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 it are true.
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ILI 40
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Printed Name
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