Sidney GoldinM AI E H
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
RECEIVED
FEB 8 2023
CITY OF iVllAMI BEACH
OFFICE O TE 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.
hom e A«ares. 541 570oL(N S yr 33/cg
□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
""gdo, ht., a//403
Signature T Date
SQ6EY GOLDIN
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means o~ysical presence or□online notarization, e_.,a/car • Slej all
(([[/ of Miami Beach Board/Committee Member).
Produced ID
-~ f Form of Identification
/ rsonally Known
- ~------
Si a f of, ic
3g3jig., CARL.Es s. GosTi
±? pd ", MY cossIoN # HH 1os7os
2j,2,is ExP REs: December 14, 2025
?3 33:7$8 °' "?gf,f's°' Bonded Thru Notary Public Underwriters
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped