Mark RabinowitzM IA M I BEA C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
MAR 19 2024
CITY OF M»
OFF!Cg gr-
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in com pliance with the affiliation requirement of Miam i Beach City Code Sections 2-22 (4),
as ( check ( ✓) all that apply):
D I am a resident of the C ity of M iam i Beach fo r six months or longer.
Hom e A ddress: _
D I have an ow nership interest (fo r a minim um of six months) in a business established in the
City of M iam i Beach (fo r a minim um of six months).
Nam e of Business: _
Business Address: _
[] am a full-tim e em ployee of a business (fo r a minim um of six months) and I am based in an
office or other location of the business that is physically located in Miam i Beach (for a
m inim um of six months).
Nam e of Business: M iam i Beach Com m unity Health Center
Business Address: 11645 Biscayne Blvd., M iam i, FL 33181
"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 fo regoing docum ent and that the facts
stated in it are true.
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03/19/2024
Date
Printed Nam e