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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 /> (Signature) <br /> (Date) <br /> STATE OFY <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this ��C day of z ,204, by <br /> ,who is verso knocn 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: J0.3. <br /> (Seal) <br /> 4pr°g'""`� DEBORAH WEST <br /> MyC0MMSSI0N#FF90M <br /> yMd,FTFXMJES:octdw 03.2019 <br /> 00452-2 <br /> F:\PublicWorks\ENGINEERING DIVISION PROJECTS\1049_8th St Sidewalk Improvements(58th Ave to 21st Court)\Admim\bid documents\LAP <br /> Documents\Master Contract Documents\00452 Disclosure of Relationships.doc <br />