Brett Burstein Sep 2022MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(c�miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
OCT '-4 2022
CITY OF MIAMI BEACH
OFFICE nr "'-;P_ (;ITS,, 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):
�i I am a resident of the City of Miami Beach for six months or longer.
Home Address 4507 S ket idan Rve lAkA.YA'% Beach FL 33140
❑ 1 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
❑ 1 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.
Signature Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physi%presence or ❑ online notarization,
this/,Vday of OC �/�' ` , 2G2�)by
Produced ID
(City of Miami Beach Board/Committee Member).
Form of Identification
Peiaonq 1y Known
Sign f N ry ublic
Name of ry, Typed, Printed, or Stamped
CHARLES J.DAG CiSTIN�
*, * MY COMwSSION # HH 165705
EXPIRES: December 14, 2025
Bonded Thru Notary public Underwiters
(NOTARY SEAL)