Spencer HenningsMIAMI BEACH RECEIVED
,JAN 2 6 2023
City of Miami Beach
1700 Convention Center Drive CITY OF MIAMI BEACH
Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email: BC(@.miamIbeachfI,gov
Telephone: 305,673.7411
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):
ra I am a resident of the City of Miami Beach for six months or longer.
Home Address5055 Collins Ave. Apt 12C. Miami Beach, FI, 33140.
0 1 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 (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
Signatilreu Date
Spencer E. Hennings
Printed Name
210 "Ta -9
Sworn to (or affirmed) and subscribed before me, by means of;? physical presence or o online notarization,
this ad day of 700) _, 20�by *OC& E -
(City of Miami Beach Board/Committee Member).
AGUSTIN RAYS
Produced ID Et- DKV05 Lcehie U
Notary NbIk - State of Fiori4a
Form of Identification Commission it HH D3120O6
Personally Known My Comm. Expires, Sep 14, 2026
(NOTARY SEAL)
Siana ure of Notary Public
Name of Notary, Typed, Printed, or Stamped