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Name of Affiliate Name of County Commissioner Relationship <br />or entity or employee <br />R <br />rA <br />[i <br />e <br />t <br />0 <br />0 <br />0 <br />'(Signature) <br />-� a <br />(Date) <br />STATE OF rt-091bP <br />COUNTY OF `5' - t -UC <br />The foregoing instrument was acknowledged before me this day •f 20_L�, by <br />who is personally known to me or who has produced <br />as identification. <br />SIGN: <br />PRIM <br />00452-2 <br />Notary Public, State at large <br />My Commission Expires: <br />. ............................................; <br />ANTOINETTE PETERSON <br />(Seal) ,s Y" Comm# DD0591199 1 <br />Expires 929/2010 <br />r-bdds Nataty Aaen•. inc <br />w u n u <br />...................... n u u.......7 <br />F:\Engineering\Capital Projects\0205 Old Dbde Highway Bridge over the South Relief Canal\0205 Contract Documents $ Specs\00452 Disclosure of <br />Relationships.cloc <br />