Tiffany LapciucOFFICE OF THE CITY CLERK
Email: BCComiamibeachft.gov
Telephone: 3 05.673.741 1
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 (.1) all that apply):
l am a resident of the City of Miami Beach for six months or longer.
Home Address: _1U1'5 ",X.r4w) Navot
❑ 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 Address:
❑ 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 ten percent (70%) or more (including the
ownership of 90% 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.
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