Donald GoldbergM IA M I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CL ERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
RECEIVED
MAY 25 2023
CITY OF MIAMI BEACH
OFFICE OF THE CI TY CLEn R
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):
l am a resident of the City of Miami Beach for six m9pths or longer.
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□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).
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□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).
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"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 pen · o rjury, I declare that I have read the foregoing document and that the facts stated in it
»'al 5/25/23
Signat Date
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Printed Nam O
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online notarization,
s25 N} as~ poncll ldbury
________ (City of Miami Beach Board/Committee Member).
pL Produced ID
Form of Identification
Name of Notary, Typed, Printed, or Stamped