Disclosure Statement
STATE OF FLORIDA
..'~'-
9'!!<li....~ Zone: 17
Lease No: 760:0403
DEPARTMENT OF MANAGEMENT SERVICES
DffiCLOSURESTATEMENT
Authority: Paragraphs 255.249(2)(h)(i), 255.01 F.S.
Check One: Privately O\Wed Entity Holding Title V Publicly Owned
Name of Entity: f1 0/1./ Roe C au I1JTy - A JfL P 0 Yl~T
Name of Facility: (]::) n.. i 1/ e_ rL LIe e AI S e..s
Facility Location:
City: Key West
Street Address: ~ L./ "3 9 South Roosevelt Blvd
County: Monroe
Zip: 33040
Total Net Rentable Square Footage in Building ,/, 7 (;, 0
FederalIdentification No. (F.I.N. or S.S.N.) 59 /;, 000 7 4 9
PUBLICLY OWNED FACILITIES COMPLETE TInS AND SIGNATURE PORTION ONLY:
IS TInS FACILITY FINANCED WITH LOCAL GOYJRNMENT OBLIGATIONS OF ANY TYPE?
YES V NO
This is to certify that the following individual(s) or entity holds 4% or more interest and/or the following public
official(s), agent(s) or employee(s) holds illY interest in the property or in the entity holding title to the property being
leased to the State.
This is to certify that all beneficial interest is represented by stock in a corporation registered with the Securities and
Exchange Commission or is registered pursuant to Chapter 517, Florida Statutes, which stock is for sale to the general
public. Yes V No
If entity is a Corporation(not registered with the Securities and Exchange Commission), provide information for any
individual holding 4% or more interest in the Corporation. If no one holds more than 4% then so state.
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
~ 0 \0
0 ."
Z )> \D -
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Or-:i: ft"!
r'Il~-< C"") 0
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00:
c:-__ (".) 0
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. 0 ~
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,.... C' - 0
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\0 0
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
(Attach additional pages if necessary)
FM 4114 (ROl/98)
10f2
Lease No.: 760:0403
The equity of all others holding interest in the above named property totals:
If a public official, agent or employee provide:
Name of individual:
Name of public agency:
Position held:
H Owner(s) is an Individual:
(Print or Type)
(Manual Signature)
(Print or Type)
(Manual Signature)
Date Signed:
H Owner(s) is Corporation,
Partnership, Trust, etc:
By:
\,
cS~-F~EAL
Signature
This is to certify that I, 5 h. to,.. I 4. Y P r 4. t.. n1 ct. n
(Print <ff Type Name)
,as----.MA& o{L
(Print r Type Title)
am authorized to sign for the required information thereon.
Date Signed: I ~ - 0 e - 9 ?
FM 4114 (ROl/98) 20f2
Disclosure Statement
Additional Page
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
Lease No.: 760:0403
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
Name:
Home Address:
Principal Occupation:
Occupational Address:
Percent of Interest:
FM 4114 (R01/98)
1b of2