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• <br />• <br />• <br />Name of Affiliatq Name of County Commissioner Relationship <br />r Entity or emviovee <br />t: <br />(V, A�& <br />si nature) <br />1 no <br />date <br />STATE OF Glnr,/-4 <br />COUNTY OF -S-7- <br />The <br />•T <br />The foregoing instrument was acknowledged before me this 1-2- day of <br />-,2000,by J, L W who is personally known to me orwho has <br />produced ape I—Nn dk, o,,oj as identification. <br />NOTARY PUBLIC <br />•: OPPgARA C 'S•.. <br />n; fomrr':! <br />to Florida at <br />�•. ``B�a ygfnmissioner <br />'• STATE OF F�O� <br />STATEMENT ON DISCLOSURE <br />SS - 2 <br />