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W <br />The entity submitting this sworn statement, or one or more of the officers, directors, <br />executives, partners, shareholders, employees, members, or agents, who are active in management <br />of the entity have the following relationships with a County Commissioner or County employee: <br />Name of Affiliate <br />or entity <br />Name of County Commissioner Relationship <br />or employee <br />(Signature) <br />(Date) <br />STATE OF <br />COUNTY OF <br />The foregoing instrument was acknowledged before me this day of , 20_, by <br />who is personally known to me or who has produced <br />as identification. <br />_ NOTARY PUBLIC <br />SIGN: <br />PRINT: <br />State of Florida at Large <br />My Commission Expires: <br />r <br />(Seal) <br />r <br />r <br />zj <br />r <br />Page 26 of 40 <br />