Bryan Goldberg Sep 2022MIAMI B
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCC@miamibeachfl.gov
Telephone: 305.673.741 1
Received August 4, 2022
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
(J) all that apply):
0 I am a resident of the City of Miami Beach for six months or longer.
Home Address 2575 Flamingo Drive Miami Beach FL 33140
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 Add
❑ 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.`
August 4th, 2022
Signature Date
Bryan Goldberg
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of cxphysical presence or o online notarization,
this
4th _day of August 20 22 by Bryan Goldberg
,
(City of Miami Beach Board/Committee Member).
X Produced ID FL. Driver's License
Form of Identification
Personally Known
Sign8turgeos J. ygoP�blicin
Name of Notary, Typed, Printed, or Stamped
CHARLES J. DAGOSTIN
MY COMMISSION # HH 165705
;r Po EXPIRES: December 14, 2025
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EXPIRES:
nded ThN Notary Pubtic Underwriters
(NOTARY SEAL)