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NAME,ADDRESS•AND_OFFICE(if applicable) Percentage of_Interest <br /> • <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 interestnahe application to th ' -St of my knowledge <br /> and:bclief. <br /> t <br /> Signature: ✓ . <br /> (Applicant) <br /> -Swornrto and subscribed before me, <br /> 4 This `1 day of •February ,20 16 <br /> - — - - - — - ANNA GORODOVAYA - - <br /> • Notary Public-State of New York <br /> Notary Publi','Statc .. rr'ro .Tl ,b NEW Yo2 No.01GO6301188 <br /> Qualified in Kings.County <br /> APRIL 'y, 2 1 My Commission Expires April 14;20�f <br /> My Commission Expires: i <br /> * Disclosure Ai-alit-tot 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 iii 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 iii the <br /> limitcel partnership. <br /> Public Hearing No: - <br /> City of Sunny Isles Beach Coinniunity Developtnciit Department <br />