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(Signature) <br /> a11sl13 <br /> (Date) <br /> STATE OF Ecca e-r flA <br /> COUNTY OF 1 N D i 4A) ��- <br /> The foregoing instrument was acknowledged before me this 1 S%lz day of F��Zzt tte-Y , 20 l 3, by <br /> f74 i r3 ►C,K L,.4 r-lr--Y , who is personally known to me or who has produced <br /> as identification. <br /> NOTARY PUBLIC <br /> SIGN: <br /> PRINT: M)q-9� <br /> Notary Public, State at large <br /> My Commission Expires: <br /> (Seal) <br /> s;. MARGARET GERGEN <br /> Commission#EE 037135 <br /> Expires October 25,2014 <br /> BadW1huTwjFain hsuarao09a&7019 <br /> FACommunity Development\Users\EDplannr\Incentives&FundingUobs Grant PrograrnUpplicationTINAL Disclosure of Relationships Form.doc <br /> Local Jobs Grant Applicant Sworn Statement on Disclosure of Relationships Page 3 of 3184 <br />