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The entity submitting this sworn statement, or one or more of the officers, <br />directors, executives, partners, shareholders, employees, members, or agents, <br />who are active in management of the entity have the following relationships with <br />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 FLORIDA <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this day of <br />, 2015, by , who is personally known to me <br />or who has produced as identification. <br />NOTARY PUBLIC <br />SIGN: <br />PRINT: <br />State of Florida at Large <br />My Commission Expires: <br />(Seal) <br />XV <br />142 <br />