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, <br /> NAME,ADDRESS AND OFFICE(if applicable) Percentage 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: A,4144,M4,9 <br /> (Applicant) C ,J/, w r1 i,/_/ 7 <br /> Sworn to and subscribed •-fore me, (/ / <br /> Th' c9-. da if - 'v. <br /> ,20 1 to <br /> .1111MbLi MY C0t MlaSlON#FF 93°17 <br /> 4 o rru. 'c, S of Flori o a at Large <br /> ,,,•;:- .1:<.,•;:., <br /> .-y = EXPIRES:June 26,2018 • <br /> ',P o1'F.;,'` Bonded Thru Notary Pubic Ur.6erx:d_rs <br /> a,vr...w.r+a ...a a:trw. <br /> My Commission Expires: 1 I?'b I/ <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 15 of 30 <br /> I <br />