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Name of Affiliate Name of County Relationship <br /> or Entity Commissioner or employee <br /> 1 . <br /> 2 . <br /> 3 . <br /> 41 <br /> 5 . <br /> 6 . <br /> 7 . <br /> 81 <br /> jet <br /> ( s nature ) <br /> ( date ) <br /> STATE OF L' <br /> COUNTY OF <br /> L� <br /> The foregoing instrument was acknowledged before jj�� e this day of <br /> 200 by � � �� Gt vivt l C,Qi of <br /> who is personally known to me or <br /> 4" premed as identification . <br /> Notary Public ( affix seal ) <br /> My Commission Expires : „ ) u n 9� o?v a <br /> COWWWWWOM <br /> � ) Expiat ,AxN �9; POtt <br /> ! Y Cl r� G � 7�- • C?'/-�- 1.0 P �° n emerrwT� a»�w.wM�1�iM! <br /> C// 14 0) /q'<, l Je (,10 LAI I) r< <br />