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entity submitting this sworn stait__ <br />shanthoiders, employees; <br />-he following relationships with a I <br />Name of C cum: Cisner <br />or emplo ee <br />E we omeers, bireciors, eNecuoves, <br />active in management c:f the enhty <br />Dr County employee: <br />Relationship <br />(Signature) <br />(Date) <br />_nstrument was acknowledged before me this t day of • , 2014, by <br />who ispersonally known to me or who has produced <br />00452-2 <br />as identification. <br />SIGN: <br />PRINT: <br />NOTARY PUBLIC <br />Y Public, State at large 3242t°tar <br />My Commission Expires: kb <br />(Seal) <br />DEBORAH WEST <br />MY COMMIEUN fi E?-; 3030 <br />111604,myrivir <br />EXPIRES: :lad= 0, 9.!'.1 5 <br />ketftettiv-q-W- <br />...ENGINEERING DIVISION PROJECTS\0845B - Old Dixie Hwy Sidewalk (38th - - r-' --E--M=0-ter Contract <br />Disclosure of Relationshios.doc <br />frr:r'fi <br />-atteStAr <br />Wk's, <br />