Elizabeth ResnickMIAMI BEACH
City of Mi ami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@m iamibe ach fl.goy
Telephone: 305.673.74ij
AFFIDAVIT OE AFFILIATION WITH THE CITY OF MIAMI BEACH
l am in compliance with the affiliation req uireme nt 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 .
.« @ [Alli(o.a f16,f 3/4]
0 I have an ownership interest (for a minimum of six months) In a business esta blished in the
City of Miami Beach (for a minimum of six months).
Name of Business: ----------------------
8 us in es s Address : ---------------------- □I am a full-time employee of a business (for a minimum of six months) and I am baaed In an
office or oth er locatio n of the business that ls physically located In Miami Beach (for a
minimum of six months).
Name of B us in ess :. _
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 compan y,
or other entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts a. . JAlzA
Signal ire Date
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Printed Name