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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 or employee <br /> I <br /> (Signature) <br /> (Date) <br /> STATE OF F&0 r/D A <br /> i <br /> COUNTY OF <br /> �J <br /> The foregoing instrument was acknowledged before me this c �day of q 45 T ,20 /6, by I <br /> �J i5N Cue C�v , who is personally known to me or who has produced <br /> as identification. <br /> nNOTARY PUBLIC <br /> SIGN: /���o�c Bim—/ <br /> PRINT: /YI o rr-� <br /> Notary Public, State at large <br /> My Commission Expires: .J'v/y 3/, Zo/6� <br /> (Seal) �o�.:'6,0SHARON M.MORRIS <br /> * MY COMMISSION I FF 135734 <br /> EXPIRES:July 31,2018 <br /> 'FOFF 09N Bonded Thru Budget Notary Services ' <br /> I <br /> i <br /> i <br /> r <br /> 1 <br /> i <br /> 00452-2 ' <br /> F:\PublicWorksENGINEERING DIVISION PROJECTS\1425-S County Park-General Use Field\Admin\bid documents\Master Contract I <br /> Documents\00452 Disclosure of Relabonships.doc <br />