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Name of Affiliate <br />or entity <br />Name of County Commissioner <br />or employee <br />Relationship <br />G <br />(Signatur <br />(Da e) <br />STATE OF <br />COUNTY OF �L�-jX'Lz'y\ <br />The foregoing instrument was acknowledged before me this day of ti1_r S� , 200 by <br />Awho is person known -me or who has produced <br />�{ as identification. <br />PY F'G@ VICKIE LEE WRIGHT N ARY PU�'b�C <br />° * * Notary Public State of Florida <br />p Aly Commission Exp• Much 11, 2012 <br />oY Commission # DD 7566&3 �., SIGN: v" <br />PRINT: <br />Notary Public, State at e <br />My Commission Expires: p'�3I <br />(Seal) <br />00452-2 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1024-17thStreet and IR Bivd IntersectionWdmim\Contract Documents\00452 Disclosure of <br />Palafinnchinc rine <br />