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X 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 or employee <br /> Sandra Wright Cousin <br /> If <br /> (Signature) <br /> 06/07/2016 <br /> (Date) <br /> STATE OF <br /> COUNTY OF %N_,)11 41 Ver,-- <br /> /C <br /> The foregoing instrument was acknowledged before me this 7_ day of _IRA4�_ , 20&,,_, by <br /> who is personally known to me or who has produced <br /> as identification. <br /> NOTARY PUBLIC <br /> SIGN: <br /> PRINT: <br /> Notary Public, State at large <br /> My Commission Expires: 7/Z//zo <br /> (Seal) <br /> my MAR !H.TUPEK <br /> � D <br /> F <br /> ;,;� •o= WM'Jody21, <br /> � d 7hru NOWY pubft <br /> 00452-2 <br /> P,\Bids\2015-2016 FY(2016000)\2016019-GoLine Transfer Hub\Bid Docs\Word forms\00452 Disclosure of Relationships.doc <br />