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1 <br /> NAME.ADDRESS AND OFFICE(if applicable) Percentage of Interest <br /> • <br /> Date of Contract: <br /> If any contingency clause or obntraot terms involve additional parties,list all individuals or officers; <br /> if a corporation,partnership or trust. • <br /> • <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 /> • <br /> The above is a full disclosure of all parties of interest in the application to the bes•of my owledge <br /> and belief. <br /> • <br /> Signature: ... <br /> (Applicant), A9�HS {—'\S Q AM-; \\5 <br /> Sworn to and subscribed before me, <br /> This G9Z day of r n, / ',20 /5 <br /> • a�' } AIEXEY BURYA. <br /> Notary r blic, Sta c of Flo i': at Large i;i %•F MY COMMISSION#FFi27898 <br /> .471- : EXPIRES June 1, 2018 <br /> • <br /> (407)758-0157 FloritlaNatoryaaMce.tom <br /> • My 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 /> Public Hearing No: <br /> City of Sunny Isles Beach Community Development Department <br />