Evan SalzbergMIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Te lep hone: 305 .673 7411
RECEIVED
FEB - 9 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(✓) all that apply):
x I am a resident of the City of Miami Beach for six months or longer.
Home Address 1670 Bay Road apt. 3A Miami Beach FL 33139
o 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 -------------------------
o 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 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. Íj£i= 2_17_1_2_2 _
Signature Date
Evan Salzberg
Printed Name
NOTARY
Sworn to ( or amif C c,;bed, before me, by means of o phys;cal_ p_resence o;~nl;ne notar;zabon,
.7a,+l»03, kUAy SA/zle)
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. .. {3 g} EXPIRES: December 14, 2025
Form of Identification $ji"" eon&ea mu Notary Powe w'ereers
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped