Jerri BassukMIAMI BEACH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
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 (check(✓) all that apply):
l/[1am a resident of the City of Miami Beach for six months or longer.
Home Address: 6601 Roxbury Ln, Miami Beach, FL 33141
D I 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).
[[are (f [[Jg[mess,
Business Address: -------------------------- □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).
[]are f [[g[res,S,
[ys1mess J([dress,
"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 r e.
5/6/24
Signature
Jerri Bassuk
Date
Printed Name
RECEIVED
MAY 03 2024
CITY + +#14Ml BEACH
OFIT TL.ERK