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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 <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this day of , 24 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 />.00452-2 . <br />FAPublic Works\ENGINEERING DIVISION PROJECTS\1736. IRC Health Department Roof Replacement ProjecM-Admin\Bid DocurnentMaster <br />Contract Ddcuments\00452 Disclosure of Relationships.doc <br />