Harvey BursteinM IA M I B EA CH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
JAN 18 2024
CITY OF MIAMI BEA CH
OFFICE OF !BE /Ty En .ii R t..
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (✓)all that apply):
[Z] I am a resident of the City of Miami Beach for six months or longer.
Hom e Address·1775 Washington Ave Miami Beach Florida 33139 United States
D 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: _
D 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" m eans 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.
Harvey J. Burstein 1/17/24
Signature
Harvey J.Burstein
Date
Printed Name