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NAME, ADDRESS AND OFFICE (if applicable) Percentat*.e of Interest <br />Date of Contract: <br />If any contingency clause or contract terms involve additional parties, list all individuals or officers, <br />if a corporation, partnership or trust, <br />For any changes of ownership or changes in contracts for purchase subsequent to the date of the <br />application, but prior to the date of final public hearing, a supplemental disclosure of interest shall <br />be filed. <br />The above is a full disclosure of all parties of interest in the application to the best of my knowledge <br />and belief. <br />Signature: <br />(Applicant)!" T511'AA <br />Sworn to and subscribed before me, <br />n l/ <br />Tltic 2 �ov of �11�D.rW <br />Public,Wate of Fl&lda at Large <br />My Commission Expires: 10 a P- <br />• • Y��„ CARMIN'TILLIT <br />Notary Public - State of Florida <br />Commission N GG 192011 <br />`•9�'o F�o-� My Comm. Expires tun 26, 2022 <br />• •'•• Bonded through National Notary Assn. <br />* Disclosure shall not be required of any entity; the equity interest is which are regularly traded on <br />an established securities market in the United States or other country; or any entity, the ownership <br />interest of which are held in a limited partnership consisting of more than 5,000 separate interest <br />and where no one person or entity holds more than a total of 5% of the ownership interest in the <br />limited partnership, <br />Public Hearing No: <br />City of Sunny Isles Beach Public Hearing Application Package Page W of 23 <br />