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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 plication to the best of my <br /> knowledge and belief. <br /> Signature: - <br /> (Applicant) <br /> Sworn to and subscribed before me, <br /> This 1 . day of 0 • /17.-- , 2015 <br /> 0 - <br /> Nota , Public, State of Flo da at Large e adl �tlNA FF =°:6:2.8c r''. <br /> \4 MY' OMMISS�O,; t c67a <br /> %* `"..2.-:.:,...,,;,,%' 1✓`�lC�1Rf=�.l2;uary 27,2013 <br /> My Commission Expires: 1 Z; I �:; ��� �"' "''s�""�`°m <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 />