Michal WeinsteinMIAMI BEACH
City of Miami Beach
17 00 C onvention C enter Drive
M iam i Beach, Florida 33 13 9
O FFIC E OF TH E C ITY C LERK
Email: BC@miamibeachfl.gov
Telephone: 305.6 73.7 4 11
RECEIVED
APR 25 2023
CITY OF MIAM I 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):
121 I am a resident of the City of Miami Beach for six months or longer.
Home Address 4630 Royal Palm Ave Miami Beach Florida 33140
□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. } 4
i~fa tultoi] March212023
Signature Date
Michal Weinstein
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by m~_a1s of~sical presence or u online notarization,
net_/Pe tt _Os /]] uUestelv
(City of ~mi Beach BoarLmmi~ee Member).
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S ig nal~ ~ ~
it&., CHARLES J, DAGO STN
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j,J9&,&j ExPees: Dooner 14,202s
jig Bon ded Tu Notary Public Underwriters
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped