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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 />STATE OF RolId- L <br />COUNTY OF \al—rArt 21JJC1--- <br />(Signature) <br />A?'Zck2GXS <br />(Date) <br />The foregoing instrument was acknowledged before me this 2,a day of <br />, who is personally known,to me or who has produced <br />as identification. <br />NOTARY PUBLIC <br />SIGN: <br />jo3 c"� e5 — <br />Notary Public, State at large <br />My Commission Expires: I0.3.15 <br />PRINT: <br />00452-2 <br />(Seal) <br />'7169 <br />s3, 2015 <br />i"J Near nipw n Awa Ca <br />*14404044 <br />F:\PublicWorks\ENGINEERING DIVISION PROJECTS\1413-Martin Luther King Walking TrailAdmin\bid documents\Master Contract <br />Documents\00452 Disclosure of Relationships.doc <br />