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Docusign Envelope ID: 9199AF63-50A4-442C-AE7A-7B4C4273688F <br />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 heating, a supplemental disclosure of interest 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) <br />Sworn to and subscribed before me, <br />This day of C. WAQXY 20 .� <br />. N EV Ar�G�F'�� <br />Notary Publi , ate of Florida at Large ?, <br />NOTARY ; <br />PUBLIC <br />Comm. 9 HH 167854 <br />My Commission Expires: My Comm. Expires <br />Aug 23.2025 <br />* Disclosure shall not be required of an entity; the e sT % <br />q y ty; qu#y iest�0t� are regularly traded on <br />an established securities market in the United States or oifi ,99 `3r 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 <br />34 <br />