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- �.�. <br /> r 1360 SW Old Dixie Hwy Suite 106 <br /> Vero %Beach , FL 32962 <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 /> 61 <br /> 7 . <br /> 8 . <br /> ( signature) <br /> c:� I CC) <br /> (date ) <br /> STATE OF <br /> COUNTY OF 1 ki0tAK iv ... <br /> Personally appeared before me , the undersigned authority, <br /> who fter first being sw rn by jo , affixed his / her sig,_n ture in the space provided above on this <br /> day of 1(� , 20 C� . <br /> GLORIA J. KUDu % <br /> MY COMMISSION # DD 719964 <br /> y' •= EXPIRES May 26. 2009 <br /> �'f pi i Bonded Thru Notary Pubic underwriters <br /> ooa• <br /> otary Public , S rege <br /> e <br /> My Commissi xpires : <br /> END OF SECTION <br /> 00452 - Disclosure of Relationships REV 04-07 . doc <br /> 00452 - 2 <br />