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_The entity submitting this sworn statement, or one or more of the <br />officers, directors, executives, partners, shareholders, employees, <br />members, or agents who are active in management of the entity have <br />the following relationships with a County Commissioner or County <br />employee <br />Name of Affiliate Name of County Commissioner Relationship <br />or Entity or employee <br />[ signature ] <br />[ date ] <br />The foregoing instrument was acknowledged before me this <br />day of , 19_, by who is personally <br />known to me or who has produced as identification. <br />sign <br />print* <br />State of Florida at Large <br />My Commissioner Expires. <br />