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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 />or entity <br />B <br />STATE OF <br />COUNTY OF �VI(�LP•{1 <br />Name of County Commissioner <br />or employee <br />Relationship <br />` (Signature) <br />(Date) <br />The foregoing instrument was aclmowledged before me this U day of , 201, by <br />who is personally known tome or who has produced <br />as identification. <br />NOTARY PUBLIC <br />F <br />SIGN: <br />PRINT: �?LEV- <br />Notary Public, State, at large <br />My Commission Expires: <br />(Seal) <br />*P'%:DEBORAH WEST <br />OMMISSION it FF904578 <br />PIRES: October 03, 2019 <br />a <br />00452-2 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1415-IR Blvd Sidewalk -37th St to 53rd SAI-Admin\bid documentsWaster Contract <br />Documents\00452 Disclosure of Relationships.doc <br />