Charlotte LibovMIAMI BEACH
City of Miami Beach
1700 'Convention Center Drive
Miami Beach, Florldo 33139
OFFICE OF THE CITY CLERK
Email: BC&miamibeachtl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
,I am in compl4ance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (J) all that apply):
e 1 am a resident of the City of Miami Beach for six months or longer.
S00 West Ave.. Apt. 415, Miami Beach, FL 33139
Home Address:
El I 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:
Business Address:
� t am a fill -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 ten percent (10%a) or more (including the
ownership of 70% 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 are true.
Signature
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Printed Name
June 2, 2023
Date