Harvey Burstein!
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City of Miami Beach
I700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf 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 appl y ).
Á-- I am a resident of the City of Miami Beach for six months or longer.
Home Address l1) l shp ,t ue )
a 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 _
P S,/[es,, J(Sf@S,
u 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 _
[[us/fess (ddfeS5
"O wners hip 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" m eans any sole pro prietorship, sponsorship, corp oration, limited liability company, or other
entity or business association.
Under penaltie of erjury, I declare that I have read the foregoing document and that the facts stated in it
are true. y /o.y-= h. _ A2/
Sig n; Ire • Date oyy E le _
Printed Name
NOTARY
sw or n to (or affiped) and subscribed before me, by means of s physical presence or e onlne n0a7a97
s2,b)ce..l • 2,. Hi t, lKS7to
(City of Miami '}yach Board/Comz:e Member). X esso [ b)al/ere yese
Form of Identification
Personally Known
Signature of Notary Public
.±., CHARLES J. DAGOSTIN
/f1ë'.t'f~R~yt ~SS ION # HH 165705
;; ¿;i EXPI RES: December 14, 2025
%..é oded mr u Notary Pub lic Underwrit ers %£.%°