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r <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 /> r <br /> Name of Affiliate Name of County Commissioner Relationship <br /> or entity or employee <br /> r <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 /> r <br /> r <br /> Page 26 of 40 <br />