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NAMEADDRESS AND OFFICE (if applicable) Percentage of Interest <br />Date of Contract: <br />if any contingency clause or co tract 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 p�icatioR to the bes�pf my knowledge <br />and belief <br />Sworn to and subscribed before me, <br />-L`rr!� <br />This , day pf <br />fp <br />Notary Nblic, State of Florida at Large <br />f^• <br />My Commission Expires: <br />(Applicant) <br />20 L <br />Ijc Icuss" Iq i <br />LL/IRIMWIoN# HH681(Mb/�A <br />. <br />ar ` EXPRE&Aupd7,2028MI <br />* Disclosure shall not be required of any entity; the equity interest is which are regularly traded on <br />an established securities inarket 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 fates Beach Public Hearing Applicatlon Package Page 16 of 23 32 <br />