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(PLEASE TYPE)
FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER:
Mark Samuelian
1 O Venetian Way
Miami Beach FL 33139
OCCUPATION: Private Investor OCCUPATION:
AMOUNT OF LOAN: $35,000.00 AMOUNT OF LOAN:
DATE RECEIVED: 6/30/2017 DA TE RECEIVED:
FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER:
OCCUPATION: OCCUPATION:
AMOUNT OF LOAN: AMOUNT OF LOAN:
DATE RECEIVED: DATE RECEIVED:
FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER:
OCCUPATION: OCCUPATION:
AMOUNT OF LOAN: AMOUNT OF LOAN:
DATE RECEIVED: . DATE RECEIVED:
DS·DE 73A (Rev. 08/03)