Donald GoldbergMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
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.
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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 _
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.
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Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, y means of□physical presence or online notarization,
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________ (City of Miami Beach Board/Committee Member).
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Form of Identification
39 %, CHARLES J. DAGOSTIN
/~~·-, MY COMMISSION# HH 165705 ¿ ·: ¿5j, sg EXPIRES; Decambor 14, 2025
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(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped