Amy RabinMIAMI BEACH
City of Miami Beach.
17DO Conventioai Cenlar Drive
Miami Bench, Florida 33139
OFFICE OF THE CITY CLERK
Email I3QAmiamibejM-_fl. pow
Telephone: 305.673,741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Cocke Sections 2-22 (4),
as (check (,I) all that apply):
a 1 am a resident of the City of Miami Beach for six months or longer,
Home Address- 331 West 28th Street Miami Beach, FL 33140
1 have an er°ship interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of sic months).
Mame of Business:
Business Address:
0 1 am a fulN`time ernployee 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:
wnershrp Interest" means the awner hip of torr pamerd (10%) or mora (including the
ownership of 10 or more of the outstanding capital stack) in a business.
TUsinessn means any sole proprietorship, sponsorship, corpofation, firrftd iiabi ty +cc mpany,
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.
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ignature Date
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PHntad Name