Michael Burnstine!BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK Email: BC@ml amjbeachfl,goy 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): ef I am a resident of the City of Miami Beach for six months or longer.
HomeAddress: )OLiq W L/1�� P'l,�; �. A, 3311./0
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).
Name of Business: ------------------------
Business Address:. _______________________ _
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: _______________________ _
Business Address: _______________________ _
"Ownership Interest" means the ownership of ten percent (10%) or more (including the ownership of 10% or mom 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
-�[-ft:_s----Signature (Y) t chu { B.imsi>ne. Date
Printed Name
RECEIVED DECEMBER 8, 2021
OFFICE OF THE CITY CLERK