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The entity submitting this sworn.,meat, or:conelor-more of the officers, directors, executives, <br />partners, shareholders, employees, ipeKn1 rs, 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 <br />or entity or employee <br />Relationship <br />STATE OF CD -c <br />COUNTY OF n E> C. <br />The foregoing instrument was acknowledged before me this -3 day of <br />. who isi ersonally known to me or who has produced <br />as identification. <br />20 \ �, " by <br />NOTARY PUBLIC <br />SIGN: �—•:� <br />PRINT: <br />00452-2 <br />Notary Public, State at large <br />My Commission Expires: <br />(Seal) <br />cilo YAMILETH HOFFMAN <br />MY COMMISSION k EE206591 <br />c11710F EXPIRES: June 10, 2016 <br />F:\Public Works\ENGINEERING DIVISION PROJECTS\1427-45th St Canal Enclosure at 43rd Ave\Admin\bid documents\Master Contract <br />Documents\00452 Disclosure of Relationships.doc <br />