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SECTION 00452 <br /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> N�A <br /> vW <br /> ignature) <br /> �h1t ) <br /> (Date) <br /> STATE OF P Oft GLAD <br /> COUNTY OF <br /> foregoing instrument was acknowledged before me this ?? day of 20 1 / . by <br /> ► ► who is personally known to me or who has produced <br /> as identification. <br /> NOTARY PUBLIC <br /> SIGN <br /> 'Y COMMISSION B DO 879160 <br /> PRINT : 2111 Au�ust 9, 2013 <br /> ti WAdwwfts <br /> Notary PubhQ,"9W@;44 <br /> My Commission Expires : <br /> (Seal) <br /> 00452-2 <br /> F:\Public Works\ENGINEERING DIVISION PROJECTW845-01d Dixie Hwy Sidewalk US1 69th (L.AP )\Admim\bId documenLs100452 Disclosure of <br /> RalatinnshinsAm. <br />