Charlotte LibovM IA M I BEACH
City of M iam i Beach
1700 Con ven tion Center Drive
Miami Beach, Florido 33139
RECEIVED
JAN 12 2024
CITY OF MIAMI BE orrcE or ~fie j ,,5 CH · CLERK
OFFICE OF THE CITY CLERK
Email. 8C@miamibeachfl.gov
Telep hon e. 305.6 73.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in com pliance w ith the affiliation requirem ent of M iam i Beach C ity Code Section s 2-22 (4),
as (check (✓) all that apply):
[l] 1 am a resident of the C ity of M iam i Beach for six m onths or longer.
Hom e Addre ss:6o 214 hoc, Gp, '/ Doa, Seal 5
D I have an ow nership interest (fo r a m inim um of six m onths) in a business established in the
C ity of M iam i Beach (for a m inim um of six m onth s).
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D I am a full-tim e em ployee of a business (fo r a m inim um of six m onths) and I am based in an
offi ce or other location of the business that is physically located in M iam i Beach (fo r a
m inim um of six m onths).
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"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.
U nder penalties of perjury , I decl are that I have read the fo regoing docum ent and that the facts
stated In it are true.
Sign a ture Date ' •
Printed Name