Robin JacobsMIAMI BE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
ECENED
MAY 14 2024
CITY OF MIAMI BEACH
OFFICE CF THE CITY CLERK
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 (9heck (/) all that apply):
[:] I am a resident of the City of Miami Beach for six months or longer.
J9me Address:_5025_Clas_Ave, a_Miami_[ea,rt33/(0
[31' 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).
Name of Business: Iw le4 -305 cdler oo /tor (~Aw. d
Business Address: Sole 905 LA2u. lo@cf,_r- 33
D 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: _
"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.
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