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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 <br />Name of County Commissioner <br />or entity <br />or employee <br />Relationship <br />STATE OF F for: <br />COUNTY OF <br />v <br />The foregoing instrument was acknowledged before me this <br />Rel <br />ature) <br />(Date) <br />day of Al. �~ <br />, 20n, by <br />, who is personally knownto me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />SIGN: '66: e -=� <br />PRINT' De_ b o tr'aln C_ ro J< e t km" <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />00452-2 <br />191 a-oih <br />It* 4segtet <br />DEBORAH A CROCKETT <br />MY COMMISSION # EE209641 <br />• <br />-r. EXPIRES June 19, 2016 <br />• I1 .. <br />(407);214153 FbAda9olxpserviae.aom <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1213-IRC Shooting Range -Skeet & Trap Improvemnts & Hunters Train Bldg\Admim\bid <br />documents\Contract Documents\00452 Disclosure of Relatinnshins.rinr. <br />