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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 OF VL <br /> COUNTY OF 0 <br /> The foregoing instrument was acknowledged before me this 1 - day ofb e-v'- 204, by <br /> -- ,who isel erso_nalLy_ n to me or who has produced <br /> as identification. <br /> NOTARY PUBLIC <br /> I ' <br /> SIGN: <br /> PRINT: tv-la" jL� <br /> Notary Public, State at large <br /> My Commission Expires:Lt . <br /> (Seal) <br /> =o<tpvP�o`� DEBORAH WEST <br /> 1 d.1 NY COMMISSION#FF904578 <br /> EXPIRES:Octo6.03,2019 <br /> 00452-2 <br /> F:\Public Works\ENGINEERING DIVISION PROJECTS\1123 43rd Ave Sidewalk Improvements 26th St.to Airport Dr West\Admim\bid <br /> documents\Master Contract Documents\00452 Disclosure of Relationships.doc <br />