Rina BassCity of Miami Beach
I7OO Convention Center Dove
Miami Bech fl&rids 331,39
RECEIVED
JAN 18 2024
CITY OF MIAMI BEACH
OFFICE r Jr CIT CLERk
OFFICE OE THE CIY CIERK
Email BC@miamibgachf.gov
Telephone. 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami each 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._(63S «4_S1" Mari (zo 3319o
E[1have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six mon th s).
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E [1am a full-time employee of a business (for a minimum of six months) and 1 am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months).
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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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true. e Mau
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Date
Printed Name