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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 <br />Name of County Commissioner Relationship <br />or entity or employee <br />(Signature) <br />(Date) <br />STATE OF AAA - <br />COUNTY OF \Ackl j f'ui( <br />The foregoing instrument was acknowledged before me this ` 1 day of Vtil <br />b , 20n , by <br />, who is personally known to me or who has produced <br />as identification. <br />SIGN: <br />PRINT: Q,3 ® .QS <br />NOTARY PUBLIC <br />Notary Public, State at large <br />My Commission Expires: t O v 3 , ► <br />(Seal) <br />00452-2 <br />DEBORAH WEST <br />IO MY COMMISSION # FF904578 <br />EXPIRES. October 03, 2019 <br />F'\Public Works\ENGINEERING DIVISION PROJECTS\1139-CR 512 Wbnd Resurfacing -Roseland Rd to US 1-SCOP\Admin\bid documents\Master <br />Contract Documents\00452 Disclosure of Relationships.doc <br />