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1 <br /> • <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 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 knowledge <br /> and belief. <br /> Signature: ( ----✓& <br /> (Applicant) filnC'/,2 (1./uta/GA_ <br /> Sworn to and subscribed before me, <br /> This day of /-(4.7i,C* ,20 LS <br /> L/ �t '+°0'r'� `F* MY COMMISSION SIONSE!IEE 3 <br /> GL .Pi(GCLC�C� 3 MYC0.4tViSSIONtEE IV-039 <br /> Notary Public, State of Florida at Larg ,,-- !p EXPIRES:February 6,2016 <br /> � <br /> i 2016 44-w me &Mel Thin gettinySarus <br /> My Commission Expires:C/is/ICt <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 Community Development Department <br />