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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 Name of County Commissioner Relationship <br /> or entity or employee <br /> _ 1 . <br /> (Si re) <br /> ('Date) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this ( day of (� L� , 20L=j.:� , by <br /> who is personally known to me or who has produced <br /> as identification. <br /> NOTARY PUBLIC <br /> SIGN : <br /> _ PRINT : Lill;GCc� �'�'�y ��- <br /> Notary Public, State at large <br /> My Commission Expires : <br /> (SeaF4041 <br /> LILIA ESTRELLA K1 ENDOZA <br /> ri1Y CQfiAMiSSiQht # EE028056EXPIRES November 26, 2014 <br /> 407} 39Q 0153 FloridalloterySerricexom <br /> 00452-2 <br /> FAPublic Works%ENGINEERING DIVISION PROJECTS\1341 -Historic Dodgertown (ika VB Sports Village) Room Renovations)1AdminVbid documents\Master Contract DocsVMaster <br />Contract <br />