Gino SantorinoMl
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
MWAY 30 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfL.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[] lam a resident of the City of Miami Beach for six months or longer.
Home Address:
he.hooeooooooeooo
[] 1have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minim um of six month s).
[3r9 ()] [11[}@SS,_»-
Business Address: -------------------------
l] 1am a full-time em ployee of a business (for a minimum of six month s) and I am based in an
office or oth er location of the business that is physically located in Miami Beach (for a
minim um of si x m on th s).
Name of Business: Mount Sinai Medical Center of Florida, Inc.
Busine ss Adara4300 Alton Road, Miami Beach, FL 33140
"Ownership Interest" means the own e rship of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"B u sine ss " m ea n s any sol e proprietorship, sponsorship, corporation, limited liability company,
or oth e r en tity or business asso cia tio n .
Under penal ties of perjury, I declare that l have read the foregoing docume nt and that the facts
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Signat ure Date
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P rint ed Nam e