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Name of Affiliate Name Of County Commissioner <br /> or entity or employee Relationship <br /> ( Signature) <br /> (bate) <br /> STATE OF l \,bVU <br /> ` •�n � <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this V�Pday of ta i ' , 20j, by <br /> who is personally known to me or who has produced <br /> JA as identification . <br /> Y PUB <br /> SIGN : <br /> PRINT : - <br /> Notary Public, State at la e <br /> My Commission Expires : 03 h �zG 1 (0 <br /> (Seal) <br /> r <br /> ��"*"L• VICKIE LEE WRIGHT <br /> 4K * No <br /> Public-State of HAS <br /> * a-+ My commission Exp. truck 11 , 2016 <br /> e y io40' commission No. EE 171452 <br /> 00452-2 <br /> F :\Public Works\ENGI NEER ING DIVISION PROJECTS\0517-OSLO ROAD 43rd Ave to 58th Ave-Phase III\Admim\bid documents\00452 Disclosure <br />