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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 />STATE OF Ft0AW <br />COUNTY Of t7X&WP <br />The foregoing instrument was acknowledged before me this Z day of ✓my 20r6 by_ <br />+�� who is personally known to me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />SIGN: _ 0%1 ' <br />PRINT: A5"- $4WP <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) d'� NEt! SHARP <br />M�'.COMMISSIOIk 1 EE319679 <br />.1 tl� ptp71tE5:l�h'�7016 <br />Page 11 of 11 <br />54 <br />P104 <br />