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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 <br />or entity <br />STATE OF <br />COUNTY OF <br />Name of County Commissioner <br />or employee <br />Relationship <br />(Signature) <br />(Date) <br />The foregoing instrument was acknowledged before me this day of .20 by <br />who is personally known 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: <br />(Seal) <br />Page 11 of 11 <br />P118 <br />