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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 <br /> in management of the entity have the following relationships with a County <br /> Commissioner or County employee : <br /> Name of Affiliate Name of County Relationship <br /> or Enti Commissioner or employee <br /> 1 . <br /> 2 . — <br /> 3 . _ <br /> 4 . <br /> 5 . <br /> 6 . <br /> (signature) <br /> (date) <br /> STATE OF <br /> � L <br /> COUNTY OF <br /> Personally appeared before me , <br /> the undersigned authority , S y� c M • 1"t `"` s °i <br /> who after first being sworn . by me , affixed his/her signature in the space provided above on this <br /> I , . of DCf , 200 $ . <br /> Z95: CHIM�y <br /> Notary R tic, State at 'ozao � r <br /> t U' nvLuu)OiOM: • . c <br /> O lic )n alr „ Jrlgnd Alp�p ' u <br /> Myr fission Expire : <br /> N : , , <br /> -rp.>_ .�,. .""ai +" .. Ills •••eirlind�� <br /> END OF SECTION <br /> 00452 - Disclosure of Relationships REV 04-07 <br /> 00452 - 2 <br /> F:\Engineering\Capital Projects\0803 17th Lane SW Roadway Improvements from 27th Ave to approx. 900 LF east of 27th Ave\0803 Contract Documents\00452 - D <br />sclosure <br /> DCS/ nd_n7 rimr. <br />