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Name of Affiliate Name of County Relationship <br /> or EntityCommissioner or employee <br /> 1 . <br /> 2 . <br /> L4 .3 . <br /> 5 . <br /> 6 . <br /> 7 . <br /> 8 . <br /> ( Signature) <br /> (Date) <br /> STATE OF <br /> COUNTY OF <br /> Personally appeared before me , the undersigned authority , <br /> who after first being sworn by me , affixed his/ her signature in the space provided above on this <br /> day of 20 <br /> Notary Public , State at large <br /> My Commission Expires : <br /> END OF SECTION <br /> 00452 -2 <br />