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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 />............................................................................................. W . . . . . . . . . . . . . . <br />The above is a full disclosure of all parties of interest in tlf ication to t est of owledge <br />and belief. <br />Signature: <br />tilptnao tm" (Applicant) Matntlei Cl'r SV -OV <br />Sworn to and subscribed before me, <br />This day of KAy , 20 ZJr <br />Notary a lic, S at o r a at Large <br />My Commission Expires: S -IMA0ZSP <br />IAA Mv <br />Nota�Y public - State 01Ronda <br />089412 <br />my Comm. E><D;� n Nattuy Assn. <br />4: gnad0dtfir0119 <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 Ines Beach Public Hearing Application Package Page 16 of 23 <br />