Harvey Burstein1`0 1 AAA I B EAC H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BCemiamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
JAN 10 2023
CITY OF MIAMI BEACH
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
(✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 1775 Washington Ave. PH 2, Miami Beach, 33139
❑ 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
❑ 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 Bu
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 penal i, of per .ury, I declare that I have read the foregoing document and that the facts stated in it
are ru ` Jan 10, 2023
Signa U re Date
Harvey J. Burstein
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or ❑ online notarization,
All
this day of _ IIAQ6�[ — , 20 Z J by Wveq J 1-I'L,4in
(City of Miami Beach Board/Committee Member). A
I/ Produced ID I-- I- ')L .
Fo fn of Identific ' n
Personally Kn
Siqnature of Notary Public
r e CRL MICHAEL ANTON VIDEN
~� Notary Public, State of Florida
Commission# HH 180881
My comm. expires Sept. 30, 2025
(NOTARY SEAL)