Jay Feldman ro`
RECEIVED
MIAMIBEACH
CITY OF MIAMI BEACH
City of Miami Beach OFFICE OF THE CITY CLERK
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: Be miamibeachfl.gov
Telephone: 305.673.741 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 (ch ck (J) all that apply):
I am a resident of the City of Miami
Beach
for six months or
longer.
Home Address: 3-1 Cs .c-Aer ;•-.r,,te c<-L .3-)%'/o
INI 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: xc, 41., e-cL. ,M')
Business Address: f( y 5 SZ! ,� ., Pit. J13 [ h,, ram,,L Ft )3)`y
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 (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 pen !ties of perjur , I declare that I have read the foregoing document and that the facts
stated it a ru
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