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� L Real Estate Conflict of Interest Certification <br />Facility Name/Location <br />Miami - Sunny Isles Beach Finance (115902-001) County: Dade <br />18070 COLLINS AVE, SUNNY ISLES BEACH FL 33160-2723 Lease: Q90000541565 <br />Execuutted f's day of <br />6Y: �✓'�t7 <br />[Insert Signature] <br />BYC lel I/ ]AC L o <br />[PRINT: nafne of entity or person] <br />Title:Q-tl� <br />NAV 40 <br />� [Insert title <br />(INTERNAL USE ONLY: 1) If A(vi)'none of the above' is selected, stop, file form with the lease/license. 2) If other <br />items are selected, submit form to Ethics.helpflusps.gov. File form and Ethics determination with the <br />lease/license.] <br />August 2017 Page 2 of 2 <br />