Kaisa LevineM IA M I BEACH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
REC EIVE D
0CT 16 2023
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OF FI CE OF TIE CITY CLER
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
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(✓) all that apply):
~ I am a resident of the City of Miami Beach for six months or longer.
Home Address: 2760 North Bay Road Miami Beach FL 33140
D 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: ------------------------- □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: -------------------------
[}[J S [@ SS [(S r@ S S .
"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 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
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October 16, 2023
Signature Date
Kaisa Levine
Printed Name