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NAME. ADDRESS AND OFFICE if applicable) Percentaize 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 intereIthhelication to the best of my knowledge <br />and belief.Signature <br />(Applicant)T— <br />Sworn to and subscribed before me, <br />This 5 day <br />Notary Public',-Stf Florida at Large <br />20 23 <br />U * MY COMMISSION # HH 172105 <br />EXPIRES: September 1, 2025 <br />My Commission Expires: 09/01/2025 <br />Bonded ThtuNotaryPubllcUndenvdters <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 <br />Public Hearing Application Package <br />Page 16 of 23 <br />59 <br />