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The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in <br />management of the entity have the following relationships with a County Commissioner or <br />County employee: <br />(Signature) <br />(Date) <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this _ day of . 20 by_ <br />who is personally known to me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />SIGN: <br />PRINT: <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />00452-2 <br />Name of Affiliate Name of County Relationship <br />or Entity Commissioner or Employee <br />F21. <br />3. <br />4. <br />S. <br />6. <br />7. <br />8. <br />(Signature) <br />(Date) <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this _ day of . 20 by_ <br />who is personally known to me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />SIGN: <br />PRINT: <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />00452-2 <br />