Faye GoldinMIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(@miamibeachfl.gov
Telephone: 305.673.741 1
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):
ElelI am a resident of the City (o, fMiami Be='t long r. o
Q 2
Home Address � t l J
�
p 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
are true. r7p
�/ / r 1) 121
Signature Date
Faye Goldin
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
this 1z'�21ay of 1(Ay J( -n , 20 L3 by FN"� (OA Orn
(City of Miami Beach Board/Committee Member).HAMFj"""'�ti
Produced ID IOit h
Form of Identification ?'
Personally KnyJwn 4 MY COMMISSION
kRES 1.3.2027
RY SEAL,Signature of otary Pu isOF F..0�•••�
Name of Notary, Typed, Printed, or Stamped MJMBN�aa'