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NAME AMMA5 AND . QpFiCE(if applicable) <br />Date of Contract: <br />kercmwe of intaicest <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 />...,.........,..,.,.r....... ,,;,.... .,.........,..., e. .,.......,......... ....,.......,.... . r.:q. 1tv.c+..I,a,....h5.. ,... .!r...e.... 0 <br />The above is a full. disclosure of all parties of interest in the application the best of my knowledge <br />and belief. <br />Signature• <br />Swom to and subscribed before me, <br />This O 20 - <br />ow pu <br />R JANE POZo <br />Notary ublic, State of Florida at Large ; KIMBERLY <br />MY COMMISSION # HH 431902 <br />,'.�OF PLOP•', EXPIRES:Auguaf 9, 2027 <br />My Commission Expires: Oil <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 <br />Page 16 of 23 <br />54 <br />