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Name of Affiliate Name of County Relationship <br /> or Entit Commissioner or em to ee <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> 6 . <br /> 7 . <br /> 8 . <br /> (signature) <br /> (date) <br /> STATE OF <br /> COUNTY OF <br /> The foregoing instrument was acknowledged before me this day of <br /> 200_ by of <br /> who is personally known to me or <br /> has produced as identification . <br /> Notary Public (affix seal ) <br /> My Commission Expires : <br /> * * END OF SECTION <br /> 00452 Disclosure of Relationships.doc <br /> 00452 - 2 <br /> J'W7-02912 Inch WM - Vero Lake EstalesWccumentskReWrlsleidding contract SpecificationsWIN52 Disclosure of Rectionships.doc Rev. 05101 <br />