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The entity submitting this sworn statement, or one or more of the officers, directors, <br /> executives, partners, shareholders, employees, members, or agents, who are active in <br /> management of the entity have the following relationships with a County Commissioner or <br /> County employee: <br /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> (signature) <br /> ( ate) <br /> STATE OF <br /> COUNTY OF _ AwVACP <br /> The foregoing instrument was acknowledged before me this 2.K day of V*my 20 0 by_ <br /> who is personally known to me or who has produced <br /> SG�f as identification. <br /> NOTARY PUBLIC <br /> SIGN: <br /> PRINT: � ��' <br /> Notary Public,State at large <br /> My Commission Expires: <br /> (Seal) ��n+r�kissS�Eettsuv _. <br /> plPlfkE4:1dg2a20t6 <br /> d <br /> Page 11 of 11 <br /> 54 <br />