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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 manement of the entity <br />have the following relationships with a County Commissioner or County, employee: <br />Name of Affiliate <br />or entity <br />STATE OF� <br />COUNTY OF �a <br />Name of County Commissioner <br />or employee <br />Relationship <br />V <br />(Date) <br />T he foregoing instrument was ed before me this_ day of Feba4tV 201L by <br />who is personally known to me or who. has produced <br />as identification. <br />NOTARY PUBLIC <br />SIG <br />PRINT:i : r 4 J kiq <br />Notary Public, State 4..large <br />My Commiss on:Expires• <br />(Seal) <br />DEsofuw L AUSTIN <br />A", <br />Commisswn # GG 1G5615 <br />b� Expose �January 6; 2022 <br />-' „Tmyfa' lin raw.sao �otis' <br />00452-2 <br />F:WhiWIC Woft ENONEERIN G DM.SI(>N PROJECTSti 7W ERC .fait C "ex Roof Rswpt mffWat-Repair PmjeMiAdmftAW DowrmftWWer <br />Contrat D=ansnts=02 DWosm'of ReWonshlps.doc <br />