David BergerMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7 411
RECEIVED
EC 28 2021
CITY OF MIAMI BEACH
OFFICE OF TH E 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):
V
Home Address [3,
I am a resident of the City of Miami Beach for six months or longer.
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□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 (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
- ->ri el sels Signature Date
Dl4 Bec4er
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
.2£a.«. D ea »2L . "D A bteV
_________ (City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Name of Notary, Typed, Printed, or Stamped
±jg. JASON SALVATORE
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