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Type text here <br />NAME. ADDRESS AND OFFICE (if applicable) <br />Date of <br />Percentage of Interest <br />If any contingency clause or contract terms involy ditional parties, list all individuals or officers, <br />if a corporation, partnership or trust. <br />For any c ges of ownership or changes in contracts for purchase subsequent to the date of the <br />appl' ton, but prior to the date of final public hearing, a supplemental disclosure of interest shall <br />fled. <br />The above is a full disclosure of all parties of interest in thjtopp7�)'cafion o the b of my knowledge <br />and belief. <br />Sienature: <br />(Applicant) 611 <br />Sworn to and subscribed before me, <br />l <br />This �rd day of O kt)'-)A� , 20 <br />r <br />n a-� -mac <br />Notary Public, State of Florida atge IRMAM. PACCIONE <br />Commission # HH 166031 <br />oe Expires December 15, 2025 <br />My Commission Expires: 9lFOFF���� Bonded ThruBudgetfttagservices <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 30 <br />373 <br />