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The entity submitting this sworn statement, or one or more of the officers , directors , <br /> executives , partners , shareholders , employees , members , or agents who are active <br /> in management of the entity have the following relationships with a County <br /> Commissioner or County employee . <br /> Name of Affiliate Name of County Relationship <br /> or Entity Commissioner or employee <br /> 1 . <br /> 2. <br /> 3 . <br /> 4. <br /> 5 . <br /> 6. <br /> 7 . <br /> 8 . <br /> (signature) <br /> Io - 9� a - og <br /> (date) <br /> _ STATE OF ne 1 o L <br /> COUNTY OF 0 <br /> Personally appeared before me , the undersigned authority, 2 C N +rO4%j <br /> who §fter first bei s or , by me , affixed his/her si nature in the space provided above on this <br /> `; day of C;� , 20�. <br /> Notary Public, State at large! <br /> My Commission Expires : <br /> END OF SECTION <br /> 00452-2 <br />