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Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> L <br /> ( Signature) <br /> � ) � :2 <br /> (Date) <br /> STATE OF idot2 `Ckav <br /> COUNTY OF � � r }� � <br /> The foregoing instrument was acknowledged before me this 95 day of , 20 by% <br /> T u S <' , who is personally known to me or who has produced <br /> Nh as identification. <br /> r- <br /> PUBLIC <br /> SIGN : <br /> PRINT : U <br /> 4,L vNotPublic, State at la e <br /> My Commission Expires : p <br /> (Seal) <br /> w •o VICKIE LEE WRiGHT <br /> Notary P <br /> ublic Slat <br /> of Florida <br /> My sionEx ► arc016 <br /> Commssion111452 <br /> td!0 <br /> 00452-2 <br /> FAIDublic Works\ENGINEERING DIVISION PROJECTS\1142Wisc Culvert Replacements\Admim\bid documents\00452 Disclosure of <br />