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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 <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 pplication to the best of my <br /> knowledge and belief. <br /> Signature: ! ,� <br /> (Applicant) 1�'� i"I i L.i aW <br /> Sworn toanbscribed before me, <br /> p <br /> This /� day of xaff ,20 /2 <br /> s • : . •, <br /> BEAIRQBAQUEDANO <br /> if Pub c,State of Florida at Large M; u' s EE 0113194 <br /> EXPIRES:June If,2015 <br /> 44.-4:7„:� Bonded Thu Natal PutAe under/dent <br /> My Commission Expires: /6 <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 />