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OWNERSHIP AFFIDAVIT <br />FOR LIMITED LIABILITY COMPANY <br />STATE OF Public Hearing No. <br />COUNTY OF <br />Before me, the undersigned authority, personally appeared <br />hereinafter the Affiant (s), who being first duly sworn by me, on oath, deposes and says: <br />1. Affiant is the manager, or managing member of the Dezer Blue Grass LLC <br />a Florida Limited Liability Company with the following <br />address: <br />18001 COLLINS AVENUE, 31ST FLOOR; SUNNY ISLES BEACH, FL 33160 <br />2. The Limited Liability Company owns or lease (circle one) the property, which is the <br />subject of the proposed hearing. <br />3. The subject property is legally described as: <br />See attached Exhibit "A" <br />4. Affiant is legally authorized to file this application for public hearing: <br />5. Affiant understands this affidavit is subject to the penalties of law for perjury and the <br />possibility of voiding of any zoning granted at public hearing. <br />6. Affiant understands that the matters attached to and made part of the application are <br />honest and true to the best of my knowledge and belief. I understan is application must <br />be complete and accurate before the application can be submitted nd t le hearing <br />advertized. <br />Wit ' �se <br />I re <br />Print in <br />'S igrse <br />Print Name <br />i-Affian 's Signature <br />Print Name <br />Sworn to and subscribed before me on theme. day of ` <br />Affiant is personally known to me or has produced ; as <br />Identification. o"; B° IRMAM. PACCIONE <br />* �• "s * Commission#HH'166031 <br />ono= Expires December 15,2025 Notary (Stamp/Seal) <br />Commission Expir <br />o, BoadedThrUfttetNotary SeNh= <br />es: <br />City of Sunny Isles Beach <br />Public Hearing Application Package <br />Page 10 of 30 <br />370 <br />