Harvey Burstein 12/31/2212/30/2020 12/30/2020
12/30/2020
12/31/2020
12/31/2020
12/31/2020
30th Dec
For
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AFFIDAVIT QF AFFILIA ION WITH THE cIg F MIAM!_BEACH
STATE OF FLORIDA
COUNTY OF /Ao ,- Qty
I am in compliance with the affiliation requirem ent of Miami Beach City Code Sections 2-22 {4).
as (check {/) al that apply}.
i am a resident of the City of Miami each for six months or ionger.
[} 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}
{] 1amatull-time employee of a business (for a minimum of six months) and 1 am based in an
office or other location of the business that is physically located in Miami Beach (for a
minimum of six months}
Ownershg interest" means the ownership of ten percent (10%) or more (including the
ownership oi 10% or more of the outstending cap#tat stock} in a business
Business eans any soie propnetorship. sponsorship, corporation, #rited eblty company,
or other enatty or business association.
Under penalties of perjury, 1 declare that I have read the foregoing document and that the facts
stated in it are true.
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Printed Nae
2-3o
Date
NOTARY
Swm to {ar affirmed} and subscribed before me, by means af ù physical presence or t? online
so. „ 30 Dec „20 13tafia4@n. In5 dlyOi y
Harvey Burstein çty cf Mam» each soard/comm#tee Member
Y FL Drivers License
Produced ID
Form of 1dentfication
si
NOTARY SEAL)
ß!',, Charles J. DAgostin .%±OS NorrY uLuc
FSTATE OF FLORIDA
Comm# GG168171
Expires 12/14/2021