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The entity submitting this sworn statement, or one or more of the officers, <br /> directors, executives, partners, shareholders, employees, members, or agents, <br /> who are active in management of the entity have the following relationships with <br /> a County Commissioner or County employee: <br /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> (Signature) <br /> (Date) <br /> STATE OF FLORIDA <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this day of <br /> , 2013, by , who is personally known to me <br /> or who has produced as identification. <br /> NOTARY PUBLIC <br /> SIGN: <br /> PRINT: <br /> State of Florida at Large <br /> My Commission Expires: <br /> (Seal) <br /> XIV <br /> 131 <br />