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V <br />The entity submitting this sworn statement, or one or more of the officers, directors, executives, <br />partners, shareholders, employees, members, or agents, who are active in management of the entity <br />have the following relationships with a County Commissioner or County employee: <br />Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />(Signature) <br />� G <br />(Date) <br />Y <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged bef;ii <br />this / qday of o 201-6--t by <br />ttj 06 e whrsonally known to r who has produced <br />dea cation <br />PRIls <br />NOTARY PUBLIC <br />Notary <br />.;� me, fit <br />216 <br />