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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 <br /> officers,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 application to the best of my <br /> knowledge and belief. , <br /> Signature: <br /> / /.) <br /> (Applicant) --167- '/// /Lj0/U <br /> Sworn to and s scribed before me <br /> -2/,This J day of Araza 20/ <br /> o Pub 'c, State of Florida at Large ^ tiry BE'ATBIZBAOUEDANO <br /> MY COMMISSION 5 EE 003131 <br /> _ d; axbEXPIRES:June 17,201n8ers <br /> / // 2,9/0 •�-v.... _--__— — <br /> nty Commission Expires: "" <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 /> City of Sunny Isles Beach Community Development Department <br />