Yechiel CimentMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida331319
OFFICE OF THE CITY CLERK
Email: IB(a�miamibe chfl.c a
Telephone: 305-673.741 1
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (,/) all that apply):
6 1 am a resident of the City of Miami Beach for six months or longer.
Home Address: 4333 Adams Avenue Miami Beach, FL 33140
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:
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
minimum of six months).
Name of Business:
Business Address:
"Ownership Interest" means the
ownership
of tern
percent
or more (including the
ownership of % or more of the
outstanding
capital
stack)
in
e business.
"Business" means any sole proprietorship, sponsors i, , corporation, limited ' lia ility company,
or ether entity or business association.
Under penalties of perjury, I declare that I have reed the foregoing document and that the facts
stated in it are true.
Sig nate re
Yechiel Ciment
Printed Name
06/27/2023
Date