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The entity submitting this swom 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 />(signature) <br />(date) <br />STATE OF 14,Q pi otv� <br />COUNTY OF <br />Personally appeared before me, the undersigned authority, KIC In Imo_ <br />who after first bein s orr� by me, affixed his/her si nature in the space provided above on this <br />day of Tp2�` , 20V? . <br />h4Vft eao^rti <br />NotaryPublic, State at large <br />My Commission Expires: <br />END OF SECTION <br />sa ALYSA A. COMFORT <br />:.: Commission DD 764786 <br />` r Expires May 26, 2012 <br />eaaaeanwTwyFain trune.eoo,9es7oti <br />00452 - Disclosure of Relationships REV 04-07 <br />00452-2 <br />FAEngineering\Caphal Projects\0206 5th ST SW & 43rd AVE Bridge Replacement & RoadwaY ImproremantS=NTRACT BID100452 - Disclosure of Relationships REV 04- <br />n9 Ai <br />Name of Affiliate <br />or Entity <br />Name of County <br />Commissioner or employee <br />Relationship <br />1. <br />2. <br />3. <br />4. <br />5. <br />6. <br />7. <br />8. <br />(signature) <br />(date) <br />STATE OF 14,Q pi otv� <br />COUNTY OF <br />Personally appeared before me, the undersigned authority, KIC In Imo_ <br />who after first bein s orr� by me, affixed his/her si nature in the space provided above on this <br />day of Tp2�` , 20V? . <br />h4Vft eao^rti <br />NotaryPublic, State at large <br />My Commission Expires: <br />END OF SECTION <br />sa ALYSA A. COMFORT <br />:.: Commission DD 764786 <br />` r Expires May 26, 2012 <br />eaaaeanwTwyFain trune.eoo,9es7oti <br />00452 - Disclosure of Relationships REV 04-07 <br />00452-2 <br />FAEngineering\Caphal Projects\0206 5th ST SW & 43rd AVE Bridge Replacement & RoadwaY ImproremantS=NTRACT BID100452 - Disclosure of Relationships REV 04- <br />n9 Ai <br />