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The entity submitting this sworn statement, or one or more of the officers, directors, executives, <br /> partners, shareholders, employees, members, or agents, who are active in management of the entity <br /> have the following relationships with a County Commissioner or County employee. <br /> _ Name of Affiliate Name of County Commissioner Relationship <br /> or entity 'p, or employee <br /> (Signature) <br /> (Date) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this ,i' ' day of `f't " , 2011_' , by <br /> n z f <br /> 1,H i' IL, a'° OF ,who is personally known to me or who has produced <br /> - as identification. <br /> NOTARY PUBLIC <br /> /;' . , { <br /> SIGN: .; <br /> PRINT: Af - 1 ' E <br /> Notary Public, State at large <br /> — My Commission Expires: <br /> (Seal) — <br /> ' DEBORAH A"-CROCKETT <br /> °5 My COMMISSION#EE209841 <br /> •• EXPIRES June 19.2016 <br /> 407 309-Q135 .� <br /> 00452-2 <br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1306 Oslo Road(E of 15th Ave SW)Pipe Culvert Improvement\Admim\bid documents\00452 <br /> Disclosure of Relations hips.doc <br />