Faye Goldin1141AAA1BEACH
RECEIVED
City of Nlianli Beach DEC 01 2021
1700 Com ontion t entu Drivc
Miami lkach, Fkj iWa 33139 CITY OF MIAMI BEACH
011ACEOF1 HE CITY CA.-FAK OFFICE OF THE CITY CLERK
Email:ibe,ggbftaqy
Telephone: 305.6 73.7411
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):
E am a resident of the City of Miami Beach for six months or longer,
Home Address:t
0 C 4 s a&-4e� av"►
0 1 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:
Business Address:
1 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:
Business Address:
"Ownership Interest" means the ownership of ten percent (109/0) 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 true
INA
Signature/
PLO
Printed Name
I. . ..................
Date A