Barbara GoicoecheaMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@mlamibeachfl.gov
Telephone: 305.673.7411
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):
□I am a resident of the City of Miami Beach for six months or longer.
Home Address 20 Island Ave #504 Miami Beach, FL 33139
□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).
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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 ACT Productions
Business Address 407 Lincoln Road #10J, Miami Beach, FL 33139
"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.
Un declare that I have read the foregoing document and that the facts stated in it
ar , 12/o/2021
-------------- Date
Barbara Marie Goicoech ea
Printed Name
NOTARY
Sworn to {or affirmed) and subscribed before me, by means of o physical presence or online notarization,
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onded through National Notary Assn.
Produced ID
./ Form of identification
Personally Known is (NOTARY SEAL)
Name of Notary, Typed, Print' d, or Stamped