Janet SilvermanCity of Mimi Beach
17 0 0 C on ven tion C enter Drive
Miami Beach, Florido 33 13 9
O FFIC E O F TH E CI TY C LERK
Em ail: BC@ rn iam ibeachfl.gov
Telephon e: 30 5.6 73.7 4 11
RECEIVED
MAR 20 2023
CITY OF MIAM oic or #ii,",E25Ac
v CLERK
AFFIDAVIT OF AF FILIATION WITH TH E CITY OF MIAM I 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 Addres6899 collin s ave. apt 1510 miam i beach, fl 33141
□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
o
□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 (fo r a minimum of six months).
Name of Business ------------------------
P[]m9, [(](JfoSS_...-----
"O wnership Interest" m eans the ownership of ten percent (10 %) or m ore (including the ownership of
10 % or m o re of the outstanding capital stock) in a business.
"B u sin ess" m e an s any sole proprie torship, spon sorship , corp oration, limi ted liability com pany, or other
en tity or busine ss association.
· s of perjury, I declare that I have read the foregoing document and that the facts stated in it
e. 3/20/2 3
ure Date
Jane Silverman
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
hi s > day of _/]eccl _2 023_by Jeer >luenn
________ (City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
__ Pers on al ly Known
Signature o!W~
gi g., AUSTIN WIESEL. jf? wco~issoi « vi toe4
±,ES,i} Ex# OE2.)
";jjjj$" Bonded Tru Notary Public Underwrilers
Name of Notary, Typed, Printed, or Stamped