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f applicable) <br />Date of <br />Percentage of Interest <br />If any contingency clause or contract terns invo 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 date of the <br />application, but prior to the date of final public hearing, a supplemental disclosure of in est 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: <br />(Applicant)A3 Atlantic Boulevard, LLC by Oren Shmueli <br />Sworn to and subscribed before me, <br />`�����i111ifllll/// <br />This �J da of NCCw► o r 20 24 ��� �1" GOOQ <br />Y � `•�� <br />BER,LA?3 iA.•.P <br />_S y <br />Nota Pu lic, State of horida at Large i 2 :• , NHH 154M <br />0d?'p <br />M Commission Expires: � 23 25 iipe�ICr►STA'tE��`��o�```\ <br />My p /Whim 111N���` <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 />16 <br />