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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 />The above is a full disclosure of all parties of interest in the applic ' th best of my knowledge <br />and belief. 07&�AA <br />Signa <br />(Applicant), rm lyi I o At ha�& 6) <br />Sworn to and subscribed before me, SKjYVLGb0n 6r656 'r (q�bo� 5flt <br />This 0- day of 20 <br />„IP, <br />Notary 'ubli e of Florida at LargeAi <br />'"'': PABLO PAIVA, SR. <br />MY COMMISSION # HH 444161 <br />EXPIRES: September 14, 2027 <br />•'rFfiF F�p,• <br />My Commission Expires: D (-/ Ioz <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 Page 16 of 23 27 <br />