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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. subsequffTc the datc--Qf 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 Rill disclosure of all pa�Sof interest is the fapplica ' o the-b�sf o1my kaowledJ e • ' . lorat g ,:•.. .,.•., <br />and belief. r __: . • . • • <br />Signature: <br />Aliplicant) c�rd1. 'N1ii01 • ' ' • , <br />Sworn to and subscribed before me, <br />This 4'I -day <br />My Commission -Expires:.... _.. ....... <br />_, 20 - 7 <br />EBERNADETTE KOPEC <br />Q # 2433023 <br />TARY PUBLIC <br />OF NEW JERSEY. <br />sion Expires April 23, 2028 <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 />34 <br />