Sidney GoldinA i"01 BE AC �ri
RECEIVED
DEC 01 202I
0(v of Miami Beach
1760 Convcnhon Ccnter [.)rive
Miami Boach. Florida 33139
CITY OF �MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email: BC a.i jAU2Lbep.t g9M
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Telephone: 305.673,74 11
AFFIDAVIT,,,OF AFFILIATION WITH THE CITY O.F ...M..I..AM_I BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (,/) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
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Home Address: I
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:
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).
Name of Business:
Business Address:
"Ownership Interest" means the ownership of ten percent (10ye) 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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Signature
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